Provider Demographics
NPI:1265478341
Name:SHETTY, RAM M (MD)
Entity Type:Individual
Prefix:MR
First Name:RAM
Middle Name:M
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 1:428 MORGANTOWN STREET
Mailing Address - Street 2:
Mailing Address - City:KINGWOOD
Mailing Address - State:WV
Mailing Address - Zip Code:26537
Mailing Address - Country:US
Mailing Address - Phone:304-329-0256
Mailing Address - Fax:304-329-0733
Practice Address - Street 1:428 MORGANTOWN STREET
Practice Address - Street 2:
Practice Address - City:KINGWOOD
Practice Address - State:WV
Practice Address - Zip Code:26537
Practice Address - Country:US
Practice Address - Phone:304-329-0256
Practice Address - Fax:304-329-0733
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVWV20093207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV20093OtherHEALTH PLAN
WV5600531000Medicaid
WV550770914005OtherBCBS
WV4018673Medicare ID - Type Unspecified
WV20093OtherHEALTH PLAN