Basic Information
| Provider Information | |||||||||
| NPI: | 1427006121 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHETTY | ||||||||
| FirstName: | SHREEDHAR | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | P.O. BOX 8500-1611 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191780001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6098157815 | ||||||||
| FaxNumber: | 6098157814 | ||||||||
| Practice Location | |||||||||
| Address1: | 446 BELLEVILLE AVENUE | ||||||||
| Address2: | |||||||||
| City: | TRENTON | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 086184502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6093944000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/04/2006 | ||||||||
| LastUpdateDate: | 09/07/2010 | ||||||||
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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 | 207R00000X | 25MA03235700 | NJ | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | P00838872 | 01 | NJ | RR MEDICARE - TRENTON | OTHER | 0106828 | 05 | NJ | MEDICAID |