Provider Demographics
NPI:1104858026
Name:SHETTY, SUDHAKAR (MD)
Entity Type:Individual
Prefix:
First Name:SUDHAKAR
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 1:71 EAST AVE
Mailing Address - Street 2:SUITE V
Mailing Address - City:NORWALK
Mailing Address - State:CT
Mailing Address - Zip Code:06851-4903
Mailing Address - Country:US
Mailing Address - Phone:203-656-1452
Mailing Address - Fax:203-656-1485
Practice Address - Street 1:71 EAST AVE
Practice Address - Street 2:SUITE V
Practice Address - City:NORWALK
Practice Address - State:CT
Practice Address - Zip Code:06851-4903
Practice Address - Country:US
Practice Address - Phone:203-656-1452
Practice Address - Fax:203-656-1485
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2013-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0375022084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001375022Medicaid
CTG92541Medicare UPIN
CT001375022Medicaid