Healthcare Provider Details

I. General information

NPI: 1194068841
Provider Name (Legal Business Name): GAURAV SHUKLA M.D., PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/01/2013
Last Update Date: 07/29/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4701 OGLETOWN STANTON RD STE 1110
NEWARK DE
19713-2079
US

IV. Provider business mailing address

4701 OGLETOWN STANTON RD STE 1109
NEWARK DE
19713-2079
US

V. Phone/Fax

Practice location:
  • Phone: 302-623-4800
  • Fax:
Mailing address:
  • Phone: 302-623-4800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License NumberMD464808
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License NumberC1-0012765
License Number StateDE
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: