Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2084N0400X | Neurologist | 141530 | NY |
NPI | 1033102280 |
---|---|
Provider Name | Dinesh Shukla |
First Address | Port Jefferson, NY 11777-2316 |
Second Address | Port Jefferson, NY 11777-2316 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 23/08/2005 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
00720892 | (05) | NY |
B16669 | (02) |