Provider Demographics
NPI:1194794610
Name:SHUKLA, MANAN S (MD)
Entity type:Individual
Prefix:
First Name:MANAN
Middle Name:S
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 1:450 W MEDICAL CENTER BLVD
Mailing Address - Street 2:SUITE 203
Mailing Address - City:WEBSTER
Mailing Address - State:TX
Mailing Address - Zip Code:77598-4234
Mailing Address - Country:US
Mailing Address - Phone:832-906-2500
Mailing Address - Fax:832-906-2501
Practice Address - Street 1:450 W MEDICAL CENTER BLVD
Practice Address - Street 2:SUITE 203
Practice Address - City:WEBSTER
Practice Address - State:TX
Practice Address - Zip Code:77598-4234
Practice Address - Country:US
Practice Address - Phone:832-906-2500
Practice Address - Fax:832-906-2501
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2020-01-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL036091485207R00000X
MN43570207R00000X
TXN9300207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036091485Medicaid
MN403226800Medicaid
IL036091485Medicaid
MN403226800Medicaid
1100074811Medicare NSC