Provider Demographics
NPI:1003820762
Name:SHUKLA, KISHORKUMAR N (MD)
Entity type:Individual
Prefix:DR
First Name:KISHORKUMAR
Middle Name:N
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 1:2501 S VOLUSIA AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:ORANGE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32763-9134
Mailing Address - Country:US
Mailing Address - Phone:386-789-9000
Mailing Address - Fax:386-775-9700
Practice Address - Street 1:2501 S VOLUSIA AVE STE 100
Practice Address - Street 2:UNIT A
Practice Address - City:ORANGE CITY
Practice Address - State:FL
Practice Address - Zip Code:32763-9134
Practice Address - Country:US
Practice Address - Phone:386-789-9000
Practice Address - Fax:386-775-9700
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-28
Last Update Date:2017-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0076361208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL255838600Medicaid
FLF96336Medicare UPIN