Provider Demographics
NPI:1164416145
Name:SHETTY, ATHMARAM (MD)
Entity Type:Individual
Prefix:
First Name:ATHMARAM
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 1:7345 WATSON RD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63119-4405
Mailing Address - Country:US
Mailing Address - Phone:314-752-7100
Mailing Address - Fax:314-752-3284
Practice Address - Street 1:7345 WATSON RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63119-4405
Practice Address - Country:US
Practice Address - Phone:314-752-7100
Practice Address - Fax:314-752-3284
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-07
Last Update Date:2017-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO104222207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO209776806Medicaid
MO209776806Medicaid
MOG51507Medicare UPIN