Provider Demographics
NPI:1184753865
Name:SHUKLA MEDICAL GROUP, LLC
Entity type:Organization
Organization Name:SHUKLA MEDICAL GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:NILESH
Authorized Official - Middle Name:B
Authorized Official - Last Name:SHUKLA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:201-286-7400
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-05
Last Update Date:2014-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07868700207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0128091Medicaid
108956Medicare PIN