Provider Demographics
NPI:1316387137
Name:SHUKLA, RAKENDU PRAKASH (MD)
Entity Type:Individual
Prefix:
First Name:RAKENDU
Middle Name:PRAKASH
Last Name:SHUKLA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:148 BILL CARRUTH PARKWAY SUITE LL30
Mailing Address - Street 2:
Mailing Address - City:HIRAM
Mailing Address - State:GA
Mailing Address - Zip Code:30141
Mailing Address - Country:US
Mailing Address - Phone:470-644-8140
Mailing Address - Fax:770-443-6654
Practice Address - Street 1:148 BILL CARRUTH PKWY STE LL30
Practice Address - Street 2:
Practice Address - City:HIRAM
Practice Address - State:GA
Practice Address - Zip Code:30141-3768
Practice Address - Country:US
Practice Address - Phone:770-505-3855
Practice Address - Fax:770-443-6654
Is Sole Proprietor?:No
Enumeration Date:2013-06-25
Last Update Date:2020-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR390200000X
GA859772085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program