Provider Demographics
NPI:1619976602
Name:SHUKLA, SHRUTI ABHIJIT (MD)
Entity type:Individual
Prefix:
First Name:SHRUTI
Middle Name:ABHIJIT
Last Name:SHUKLA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 HIGH PARK AVE
Mailing Address - Street 2:
Mailing Address - City:GOSHEN
Mailing Address - State:IN
Mailing Address - Zip Code:46526-4810
Mailing Address - Country:US
Mailing Address - Phone:574-533-2141
Mailing Address - Fax:574-364-2777
Practice Address - Street 1:200 HIGH PARK AVE
Practice Address - Street 2:
Practice Address - City:GOSHEN
Practice Address - State:IN
Practice Address - Zip Code:46526-4810
Practice Address - Country:US
Practice Address - Phone:574-533-2141
Practice Address - Fax:574-364-2777
Is Sole Proprietor?:No
Enumeration Date:2005-07-20
Last Update Date:2025-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01061384A207ZF0201X, 207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No207ZF0201XAllopathic & Osteopathic PhysiciansPathologyForensic Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000587062OtherANTHEM BC/BS
OH2544803Medicaid
INP00704762OtherRAILROAD MEDICARE
IN200818460Medicaid
IN000000487828OtherANTHEM BC/BS
OH2544803Medicaid
IN200818460Medicaid