Provider Demographics
NPI:1619983558
Name:SHUKLA, MANISH M (MD)
Entity Type:Individual
Prefix:MR
First Name:MANISH
Middle Name:M
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 1:3943 W 31ST ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60623-4936
Mailing Address - Country:US
Mailing Address - Phone:773-523-8773
Mailing Address - Fax:773-523-9259
Practice Address - Street 1:3943 W 31ST ST
Practice Address - Street 2:ST JUDE MEDICAL CENTER
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60623-4936
Practice Address - Country:US
Practice Address - Phone:773-523-8773
Practice Address - Fax:773-523-9259
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2020-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036098634207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036098634Medicaid
IL551470Medicare PIN