Provider Demographics
NPI:1861487431
Name:SHUKLA, GUNJAN J (MD)
Entity type:Individual
Prefix:
First Name:GUNJAN
Middle Name:J
Last Name:SHUKLA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:82 LYONS PL
Mailing Address - Street 2:
Mailing Address - City:WESTWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07675-1828
Mailing Address - Country:US
Mailing Address - Phone:201-996-2997
Mailing Address - Fax:201-996-2571
Practice Address - Street 1:20 PROSPECT AVE
Practice Address - Street 2:SUITE 701
Practice Address - City:HACKENSACK
Practice Address - State:NJ
Practice Address - Zip Code:07601-1997
Practice Address - Country:US
Practice Address - Phone:201-996-2997
Practice Address - Fax:201-996-2571
Is Sole Proprietor?:No
Enumeration Date:2005-09-20
Last Update Date:2008-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA212477207RC0000X
NJ25MA08120200207RC0001X
NY241443207RC0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac Electrophysiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0130745Medicaid
MA2030390Medicaid
NJ0155478OtherGHI PPO
MA2030390Medicaid
NJ111686PHEMedicare PIN
NJ0155478OtherGHI PPO