Basic Information
| Provider Information | |||||||||
| NPI: | 1467402057 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHUKLA | ||||||||
| FirstName: | MANJUL | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 5 NEPONSET ST FL STREET12 | ||||||||
| Address2: | |||||||||
| City: | WORCESTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 016062714 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5085952300 | ||||||||
| FaxNumber: | 5088535226 | ||||||||
| Practice Location | |||||||||
| Address1: | 5 NEPONSET ST | ||||||||
| Address2: | |||||||||
| City: | WORCESTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 016062714 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5085952300 | ||||||||
| FaxNumber: | 5088535226 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2006 | ||||||||
| LastUpdateDate: | 09/14/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 48854 | MA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 042472266 | 01 | ONE HEALTH PLAN | OTHER | AA1250 | 01 | HARVARD PILGRIM HLTHCARE | OTHER | B01040 | 01 | BLUE SHIELD HMO BLUE | OTHER | 1061411 | 01 | FIRST HEALTH | OTHER | 9773216 | 01 | CIGNA HEALTH PLAN | OTHER | B01040 | 01 | BLUE CARE ELECT | OTHER | 0401702 | 01 | EVERCARE | OTHER | 042472266 | 01 | PRIVATE HEALTHCARE SYSTEM | OTHER | 9900237 | 01 | FALLON COMM HEALTH PLAN | OTHER | B01040 | 01 | BLUE SHIELD INDEMNITY | OTHER | 0178322 | 05 | MA | MEDICAID | 27075 | 01 | CHILDRENS MED SECUR PLAN | OTHER | 7432340 | 01 | US HEALTHCARE | OTHER | 784196 | 01 | MVP HEALTH CARE | OTHER | 0174196 | 01 | MEDICAID WELFARE | OTHER | 27075 | 01 | HEALTHY START | OTHER | 7432340 | 01 | AETNA | OTHER |