Provider Demographics
NPI:1235133190
Name:SHETTY, SHIVAPRASAD K (MD)
Entity Type:Individual
Prefix:DR
First Name:SHIVAPRASAD
Middle Name:K
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 1:240 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MORENCI
Mailing Address - State:MI
Mailing Address - Zip Code:49256-1455
Mailing Address - Country:US
Mailing Address - Phone:517-458-6848
Mailing Address - Fax:517-458-7614
Practice Address - Street 1:240 W MAIN ST
Practice Address - Street 2:
Practice Address - City:MORENCI
Practice Address - State:MI
Practice Address - Zip Code:49256-1455
Practice Address - Country:US
Practice Address - Phone:517-458-6848
Practice Address - Fax:517-458-7614
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-09
Last Update Date:2023-11-03
Deactivation Date:2006-03-15
Deactivation Code:
Reactivation Date:2006-03-21
Provider Licenses
StateLicense IDTaxonomies
OH35068087S207Q00000X
MI4301062948207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0152338Medicaid
MI3459792Medicaid
OH0152338Medicaid
OHH130890Medicare PIN
MIF98409Medicare UPIN
MION82990001Medicare PIN