Provider Demographics
NPI:1629042494
Name:SHUKLA, MANOJKUMAR B (MD)
Entity Type:Individual
Prefix:DR
First Name:MANOJKUMAR
Middle Name:B
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 1:5616 W NORVELL BRYANT HWY
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL RIVER
Mailing Address - State:FL
Mailing Address - Zip Code:34429-7572
Mailing Address - Country:US
Mailing Address - Phone:352-795-1999
Mailing Address - Fax:352-795-2269
Practice Address - Street 1:5616 W NORVELL BRYANT HWY
Practice Address - Street 2:
Practice Address - City:CRYSTAL RIVER
Practice Address - State:FL
Practice Address - Zip Code:34429-7572
Practice Address - Country:US
Practice Address - Phone:352-795-1999
Practice Address - Fax:352-795-2269
Is Sole Proprietor?:No
Enumeration Date:2006-02-16
Last Update Date:2019-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0040661207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL257109900Medicaid
FL79720OtherBLUE CROSS BLUE SHIELD
FL010004202OtherRAILROAD MEDICARE
FL167280OtherBLACK LUNG
FL79720YMedicare ID - Type Unspecified
FL010004202OtherRAILROAD MEDICARE