Healthcare Provider Details

I. General information

NPI: 1619976602
Provider Name (Legal Business Name): SHRUTI ABHIJIT SHUKLA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2005
Last Update Date: 03/03/2025
Certification Date: 03/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 HIGH PARK AVE
GOSHEN IN
46526-4810
US

IV. Provider business mailing address

200 HIGH PARK AVE
GOSHEN IN
46526-4810
US

V. Phone/Fax

Practice location:
  • Phone: 574-533-2141
  • Fax: 574-364-2777
Mailing address:
  • Phone: 574-533-2141
  • Fax: 574-364-2777

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZF0201X
TaxonomyForensic Pathology Physician
License Number01061384A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number01061384A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: