Basic Information
| Provider Information | |||||||||
| NPI: | 1225083272 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHETH | ||||||||
| FirstName: | MANISH | ||||||||
| MiddleName: | V | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4510 EXECUTIVE DRIVE | ||||||||
| Address2: | SUITE 115 | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92121 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8584275060 | ||||||||
| FaxNumber: | 6193836701 | ||||||||
| Practice Location | |||||||||
| Address1: | 4510 EXECUTIVE DR | ||||||||
| Address2: | SUITE 115 | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921213021 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8584275060 | ||||||||
| FaxNumber: | 6193836701 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2006 | ||||||||
| LastUpdateDate: | 04/02/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 5295 | SD | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084P0800X | 46626 | MN | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084P0800X | C53102 | CA | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 040121002 | 01 | MN | PRIMEWEST | OTHER | 22037 | 01 | SANFORD HEALTH PLAN | OTHER | HP40279 | 01 | SD | HEALTHPARTNERS | OTHER | 241810 | 01 | SD | MIDLANDS CHOICE | OTHER | 57108C035 | 01 | SD | WPS TRICARE | OTHER | 12200 | 05 | ND | MEDICAID | 1225083272 | 05 | IA | MEDICAID | 370624200 | 01 | SD | DEPT OF LABOR | OTHER | 4993237 | 01 | SD | BLUE CROSS | OTHER | C53102 | 01 | CA | CALIFORNIA MEDICAL LICENSE | OTHER | 1225083272 | 01 | SD | ARAZ/ AMERICA'S PPO | OTHER | 412991040284 | 01 | SD | PREFERRED ONE | OTHER | 5G434SH | 01 | MN | CC SYSTEMS/ BLUE PLUS | OTHER | 7101604 | 05 | SD | MEDICAID | 5295 | 01 | SD | DAKOTACARE | OTHER | 170133900 | 05 | MN | MEDICAID | 46022474352 | 05 | NE | MEDICAID | 5G434SH | 01 | SD | BLUE PLUS | OTHER |