Provider Demographics
NPI:1245595453
Name:SHUKLA, VIJETA (MD)
Entity Type:Individual
Prefix:DR
First Name:VIJETA
Middle Name:
Last Name:SHUKLA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 W. PARK ST.
Mailing Address - Street 2:FAPC
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61801
Mailing Address - Country:US
Mailing Address - Phone:217-902-5291
Mailing Address - Fax:
Practice Address - Street 1:611 W PARK ST
Practice Address - Street 2:
Practice Address - City:URBANA
Practice Address - State:IL
Practice Address - Zip Code:61801
Practice Address - Country:US
Practice Address - Phone:217-383-3311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-13
Last Update Date:2022-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036150115208000000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program