Healthcare Provider Details

I. General information

NPI: 1003820762
Provider Name (Legal Business Name): KISHORKUMAR N SHUKLA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/28/2006
Last Update Date: 03/22/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2501 S VOLUSIA AVE STE 100 UNIT A
ORANGE CITY FL
32763-9134
US

IV. Provider business mailing address

2501 S VOLUSIA AVE STE 100
ORANGE CITY FL
32763-9134
US

V. Phone/Fax

Practice location:
  • Phone: 386-789-9000
  • Fax: 386-775-9700
Mailing address:
  • Phone: 386-789-9000
  • Fax: 386-775-9700

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME0076361
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: