Provider Demographics
NPI:1275517526
Name:SHETTY, PRABHKAR K (MD)
Entity Type:Individual
Prefix:DR
First Name:PRABHKAR
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:PO BOX 7392
Mailing Address - Street 2:VILLAGE WEST II
Mailing Address - City:LACONIA
Mailing Address - State:NH
Mailing Address - Zip Code:03247-7392
Mailing Address - Country:US
Mailing Address - Phone:603-524-8020
Mailing Address - Fax:603-527-0271
Practice Address - Street 1:36 COUNTRY CLUB RD
Practice Address - Street 2:
Practice Address - City:GILFORD
Practice Address - State:NH
Practice Address - Zip Code:03249-6978
Practice Address - Country:US
Practice Address - Phone:603-524-8020
Practice Address - Fax:603-527-0271
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-30
Last Update Date:2014-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH4969174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH81183853Medicaid
NH0103853Y0NH01OtherANTHEM BLUE CROSS
NH6090OtherCIGNA
NHC65929Medicare UPIN
NHNH3853Medicare ID - Type UnspecifiedMEDICARE