Healthcare Provider Details

I. General information

NPI: 1437656154
Provider Name (Legal Business Name): UTKARSH CHRIS SHUKLA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/09/2018
Last Update Date: 08/23/2023
Certification Date: 08/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4901 LANG AVE NE
ALBUQUERQUE NM
87109-4397
US

IV. Provider business mailing address

480 MAIN ST APT 426
MALDEN MA
02148-5142
US

V. Phone/Fax

Practice location:
  • Phone: 505-842-8171
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License NumberMD2023-0189
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: