Provider Demographics
NPI:1710058334
Name:SHUKLA, NILESH B (MD)
Entity Type:Individual
Prefix:DR
First Name:NILESH
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:P.O. BOX 932
Mailing Address - Street 2:
Mailing Address - City:GLEN ROCK
Mailing Address - State:NJ
Mailing Address - Zip Code:07452
Mailing Address - Country:US
Mailing Address - Phone:201-652-8800
Mailing Address - Fax:201-444-8560
Practice Address - Street 1:1 W. RIDGEWOOD AVENUE
Practice Address - Street 2:SUITE 203
Practice Address - City:PARAMUS
Practice Address - State:NJ
Practice Address - Zip Code:07652
Practice Address - Country:US
Practice Address - Phone:201-652-8800
Practice Address - Fax:201-444-8560
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-13
Last Update Date:2014-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07868700207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
091420Medicare ID - Type Unspecified
NJG96940Medicare UPIN