Provider Demographics
NPI:1851684930
Name:RAJEEV SHUKLA MD
Entity type:Organization
Organization Name:RAJEEV SHUKLA MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RAJEEV
Authorized Official - Middle Name:
Authorized Official - Last Name:SHUKLA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:209-712-7017
Mailing Address - Street 1:845 S FAIRMONT AVE STE 135
Mailing Address - Street 2:
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95240-3971
Mailing Address - Country:US
Mailing Address - Phone:209-224-5385
Mailing Address - Fax:202-224-8132
Practice Address - Street 1:854 S. FAIRMONT AVE
Practice Address - Street 2:SUITE #1
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95240-3971
Practice Address - Country:US
Practice Address - Phone:209-242-5385
Practice Address - Fax:209-224-8132
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-23
Last Update Date:2025-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261Q00000X
CAA51690207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Single Specialty