Provider Demographics
NPI:1881625333
Name:SHUKLA, MANGESH (MD)
Entity type:Individual
Prefix:MR
First Name:MANGESH
Middle Name:
Last Name:SHUKLA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:MR
Other - First Name:MIKE
Other - Middle Name:
Other - Last Name:SHUKLA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:2415 N ORANGE AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32804-5505
Mailing Address - Country:US
Mailing Address - Phone:407-303-1812
Mailing Address - Fax:407-303-1815
Practice Address - Street 1:2415 N ORANGE AVE STE 200
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32804-5505
Practice Address - Country:US
Practice Address - Phone:407-303-1812
Practice Address - Fax:407-303-1815
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2025-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME126351207RG0100X
AL18418207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLVA025OtherMEDICARE HF
AL009954105Medicaid
FL016838000Medicaid