Provider Demographics
NPI:1639245533
Name:SHUKLA, JAGRUTI (MD)
Entity Type:Individual
Prefix:
First Name:JAGRUTI
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 1:52 SAN JOSE AVE
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94110-3032
Mailing Address - Country:US
Mailing Address - Phone:650-573-2222
Mailing Address - Fax:
Practice Address - Street 1:222 W 39TH AVE
Practice Address - Street 2:
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94403-4364
Practice Address - Country:US
Practice Address - Phone:650-573-2222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA71469207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A714690Medicaid
CA00A714691Medicare ID - Type Unspecified
CA00A714690Medicaid