Basic Information
| Provider Information | |||||||||
| NPI: | 1235172248 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHUKLA | ||||||||
| FirstName: | PREM | ||||||||
| MiddleName: | C | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3506 SPEEDWAY APT 204 | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787051551 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8003422898 | ||||||||
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| Practice Location | |||||||||
| Address1: | 265 BROOKVIEW CENTRE WAY STE 400 | ||||||||
| Address2: | |||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 379194052 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8003422898 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2006 | ||||||||
| LastUpdateDate: | 08/15/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | K6929 | TX | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0065PT | 01 | TX | BCBS | OTHER | 043985335 | 05 | TX | MEDICAID | P01157825 | 01 | TX | RAILROAD MEDICARE | OTHER |