Healthcare Provider Details

I. General information

NPI: 1417902768
Provider Name (Legal Business Name): PRATIK ROHIT SHUKLA DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2006
Last Update Date: 02/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

425 BRIGHTON ST #303
BETHLEHEM PA
18015-1273
US

IV. Provider business mailing address

95 HIGHLAND AVE STE 130
BETHLEHEM PA
18017-9483
US

V. Phone/Fax

Practice location:
  • Phone: 610-868-1100
  • Fax: 610-868-1111
Mailing address:
  • Phone: 610-868-1100
  • Fax: 610-868-1111

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License NumberOS010600L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: