=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821167719
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JYOTINDRA D. SHUKLA M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/07/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 210 NORTH MAIN STREET
-----------------------------------------------------
City | SALEM
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 65560
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 573-729-3711
-----------------------------------------------------
Fax | 573-729-3015
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 270
-----------------------------------------------------
City | SALEM
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 65560-0270
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 573-729-3711
-----------------------------------------------------
Fax | 573-729-3015
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | R7177
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------