Provider Demographics
NPI:1285861294
Name:SHETTY, NISHA (MD)
Entity Type:Individual
Prefix:
First Name:NISHA
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 1:10010 KENNERLY RD
Mailing Address - Street 2:3 SOUTHBRIDGE
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63128-2106
Mailing Address - Country:US
Mailing Address - Phone:314-525-1328
Mailing Address - Fax:314-525-1378
Practice Address - Street 1:10010 KENNERLY RD
Practice Address - Street 2:3 SOUTHBRIDGE
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63128-2106
Practice Address - Country:US
Practice Address - Phone:314-525-1328
Practice Address - Fax:314-525-1378
Is Sole Proprietor?:No
Enumeration Date:2009-06-17
Last Update Date:2017-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125:056663207R00000X
MO2012017119207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine