Provider Demographics
NPI:1225120892
Name:SHETTY, NIKITA (MD)
Entity Type:Individual
Prefix:
First Name:NIKITA
Middle Name:
Last Name:SHETTY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10167 N PONDEROSA DR
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93720-3418
Mailing Address - Country:US
Mailing Address - Phone:559-433-3473
Mailing Address - Fax:559-896-0400
Practice Address - Street 1:10167 N PONDEROSA DR
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720-3418
Practice Address - Country:US
Practice Address - Phone:559-433-3473
Practice Address - Fax:559-896-0400
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2010-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN46409207Q00000X
CAA102024207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN358663400Medicaid
MNI05348Medicare UPIN
MN080013306Medicare ID - Type Unspecified