1174680235 NPI number — MR. KAUSTUBH G SHUKLA R PH

Table of content: MR. KAUSTUBH G SHUKLA R PH (NPI 1174680235)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174680235 NPI number — MR. KAUSTUBH G SHUKLA R PH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHUKLA
Provider First Name:
KAUSTUBH
Provider Middle Name:
G
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
R PH
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SHUKLA
Provider Other First Name:
KAUSTUBH
Provider Other Middle Name:
G
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1174680235
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3 SANDRA DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EDISON
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08820-1900
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
603 W 4TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PLAINFIELD
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07060-2006
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
908-756-2599
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/01/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 183500000X , with the licence number:  28RI02189100 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)