Provider Demographics
NPI:1013192384
Name:SHETTY, SAFAL (MD)
Entity Type:Individual
Prefix:
First Name:SAFAL
Middle Name:
Last Name:SHETTY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6001 PROFESSIONAL PKWY STE 2020
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30134-5632
Mailing Address - Country:US
Mailing Address - Phone:770-422-1372
Mailing Address - Fax:
Practice Address - Street 1:6001 PROFESSIONAL PKWY STE 2020
Practice Address - Street 2:
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30134-5632
Practice Address - Country:US
Practice Address - Phone:770-422-1372
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-07
Last Update Date:2019-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT57280207RS0012X
GA83690207RS0012X, 207RP1001X
AZ46703207RS0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA37324OtherLOUISIANA CONTROLLED DANGEROUS SUBSTANCE