Basic Information
| Provider Information | |||||||||
| NPI: | 1518196112 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHUKLA | ||||||||
| FirstName: | SAMARTH | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 44008 | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322314008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042443660 | ||||||||
| FaxNumber: | 9042443425 | ||||||||
| Practice Location | |||||||||
| Address1: | 655 W 8TH ST | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322096511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042444242 | ||||||||
| FaxNumber: | 9042443425 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2009 | ||||||||
| LastUpdateDate: | 03/24/2016 | ||||||||
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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 | 208000000X | MT194406 | PA | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | ME124490 | FL | N | Allopathic & Osteopathic Physicians | Pediatrics | 2080N0001X | ME124490 | FL | Y | Allopathic & Osteopathic Physicians | Pediatrics | Neonatal-Perinatal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 015078800 | 05 | FL | MEDICAID | 003163416A | 05 | GA | MEDICAID |