1861487431 NPI number — GUNJAN J SHUKLA MD

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861487431 NPI number — GUNJAN J SHUKLA MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHUKLA
Provider First Name:
GUNJAN
Provider Middle Name:
J
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1861487431
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/02/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
82 LYONS PL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WESTWOOD
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07675-1828
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
201-996-2997
Provider Business Mailing Address Fax Number:
201-996-2571

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
20 PROSPECT AVE
Provider Second Line Business Practice Location Address:
SUITE 701
Provider Business Practice Location Address City Name:
HACKENSACK
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07601-1997
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
201-996-2997
Provider Business Practice Location Address Fax Number:
201-996-2571
Provider Enumeration Date:
09/20/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RC0000X , with the licence number:  212477 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RC0001X , with the licence number: 25MA08120200 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207RC0001X , with the licence number: 241443 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0130745 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2030390 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0155478 . This is a "GHI PPO" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".




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