Provider Demographics
NPI:1245330182
Name:SHUKLA, SIMA (MD)
Entity type:Individual
Prefix:DR
First Name:SIMA
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 1:1860 TOWN CENTER DRIVE
Mailing Address - Street 2:SUITE # 210
Mailing Address - City:RESTON
Mailing Address - State:VA
Mailing Address - Zip Code:20190
Mailing Address - Country:US
Mailing Address - Phone:703-481-6999
Mailing Address - Fax:703-437-1101
Practice Address - Street 1:1860 TOWN CENTER DRIVE
Practice Address - Street 2:SUITE # 210
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20190
Practice Address - Country:US
Practice Address - Phone:703-481-6999
Practice Address - Fax:703-437-1101
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-22
Last Update Date:2013-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101227766207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA5806844Medicaid
VA490922Medicare ID - Type Unspecified
VA5806844Medicaid