1053775189 NPI number — VIKRAM R. SHUKLA, MD CHILD, ADOLESCENT & ADULT PSYCHIATRY SERVICES

Table of content: (NPI 1053775189)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053775189 NPI number — VIKRAM R. SHUKLA, MD CHILD, ADOLESCENT & ADULT PSYCHIATRY SERVICES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VIKRAM R. SHUKLA, MD CHILD, ADOLESCENT & ADULT PSYCHIATRY SERVICES
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1053775189
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/05/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1100 VERDANT RIDGE CIR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BELMONT
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28012-7805
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-868-8988
Provider Business Mailing Address Fax Number:
704-868-9948

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
839 MAJESTIC CT
Provider Second Line Business Practice Location Address:
SUITE 8
Provider Business Practice Location Address City Name:
GASTONIA
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28054-5147
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-868-8988
Provider Business Practice Location Address Fax Number:
704-868-9948
Provider Enumeration Date:
04/05/2016

Additional Information

Authorized Official

Authorized Official Last Name:
SHUKLA
Authorized Official First Name:
VIKRAM
Authorized Official Middle Name:
R
Authorized Official Title or Position:
SOLE PROPRIETOR
Authorized Official Telephone Number:
704-868-8988

Provider Taxonomy Codes

  • Taxonomy code: 2084P0800X , with the licence number:  33304 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 8976031 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 11096051 . This is a "CAQH ID" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 33304 . This is a "STATE LICENSE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 2084P0804X . This is a "TAXONOMY" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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