Provider Demographics
NPI:1194068841
Name:SHUKLA, GAURAV (MD, PHD)
Entity type:Individual
Prefix:DR
First Name:GAURAV
Middle Name:
Last Name:SHUKLA
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4701 OGLETOWN STANTON RD STE 1109
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:DE
Mailing Address - Zip Code:19713-2079
Mailing Address - Country:US
Mailing Address - Phone:302-623-4800
Mailing Address - Fax:
Practice Address - Street 1:4701 OGLETOWN STANTON RD STE 1110
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19713-2079
Practice Address - Country:US
Practice Address - Phone:302-623-4800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-01
Last Update Date:2019-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD4648082085R0001X
DEC1-00127652085R0001X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program