Basic Information
| Provider Information | |||||||||
| NPI: | 1871574913 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHETTY | ||||||||
| FirstName: | SUGANDH | ||||||||
| MiddleName: | D | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 31157 WOODWARD AVE | ||||||||
| Address2: | |||||||||
| City: | ROYAL OAK | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480730926 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2483360123 | ||||||||
| FaxNumber: | 2483363190 | ||||||||
| Practice Location | |||||||||
| Address1: | 31157 WOODWARD AVE | ||||||||
| Address2: | |||||||||
| City: | ROYAL OAK | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480730926 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2483360123 | ||||||||
| FaxNumber: | 2483363190 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/07/2005 | ||||||||
| LastUpdateDate: | 07/14/2007 | ||||||||
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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 | 208800000X | 4301058781 | MI | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 4202425 | 05 | MI | MEDICAID | 4973480 | 05 | MI | MEDICAID | SS058781 | 01 | MI | BCBSM LICENSE NUMBER | OTHER | 5809584 | 01 | MI | AETNA | OTHER | G84304 | 01 | MI | HAP | OTHER | 131406 | 01 | MI | PREFERRED CARE CHOICES | OTHER | 3406338651 | 01 | MI | BCBSM INDIVIDUAL NUMBER | OTHER | C7348 | 01 | MI | MCARE PIN | OTHER |