Provider Demographics
NPI:1215178074
Name:SHETTY, ASHWIN JAYAPRAKASH (MD)
Entity Type:Individual
Prefix:DR
First Name:ASHWIN
Middle Name:JAYAPRAKASH
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 1:777 S BROAD ST
Mailing Address - Street 2:APT. #305
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19147-2508
Mailing Address - Country:US
Mailing Address - Phone:215-292-8745
Mailing Address - Fax:
Practice Address - Street 1:3401 N BROAD ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19140-5103
Practice Address - Country:US
Practice Address - Phone:215-707-4213
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-03-09
Last Update Date:2011-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT1887512085R0202X
PAMD4400052085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology