Provider Demographics
NPI:1053775189
Name:VIKRAM R. SHUKLA, MD CHILD, ADOLESCENT & ADULT PSYCHIATRY SERVICES
Entity type:Organization
Organization Name:VIKRAM R. SHUKLA, MD CHILD, ADOLESCENT & ADULT PSYCHIATRY SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE PROPRIETOR
Authorized Official - Prefix:
Authorized Official - First Name:VIKRAM
Authorized Official - Middle Name:R
Authorized Official - Last Name:SHUKLA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:704-868-8988
Mailing Address - Street 1:1100 VERDANT RIDGE CIR
Mailing Address - Street 2:
Mailing Address - City:BELMONT
Mailing Address - State:NC
Mailing Address - Zip Code:28012-7805
Mailing Address - Country:US
Mailing Address - Phone:704-868-8988
Mailing Address - Fax:704-868-9948
Practice Address - Street 1:839 MAJESTIC CT
Practice Address - Street 2:SUITE 8
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-5147
Practice Address - Country:US
Practice Address - Phone:704-868-8988
Practice Address - Fax:704-868-9948
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-05
Last Update Date:2016-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC333042084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8976031Medicaid
NC11096051OtherCAQH ID
NC33304OtherSTATE LICENSE
NC2084P0804XOtherTAXONOMY
NC21311Medicare UPIN