Provider Demographics
NPI:1386678290
Name:SHETTY, MAHADEVAN (MD)
Entity Type:Individual
Prefix:
First Name:MAHADEVAN
Middle Name:
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 1:385 MAIN ST S,
Mailing Address - Street 2:C/O NVRA UNION SQUARE BLDG #1
Mailing Address - City:SOUTHBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06488-4240
Mailing Address - Country:US
Mailing Address - Phone:203-264-7999
Mailing Address - Fax:203-264-7477
Practice Address - Street 1:385 MAIN ST S,
Practice Address - Street 2:C/O NVRA UNION SQUARE BLDG#1
Practice Address - City:SOUTHBURY
Practice Address - State:CT
Practice Address - Zip Code:06488-4240
Practice Address - Country:US
Practice Address - Phone:203-264-7999
Practice Address - Fax:203-264-7477
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2010-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0204212085N0700X, 2085R0202X, 2085U0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
No2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Ultrasound
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001204213Medicaid
B38708Medicare UPIN
CT300000582Medicare ID - Type UnspecifiedHIA
CT300002146Medicare ID - Type UnspecifiedDIA
CT300003517Medicare ID - Type UnspecifiedNDI
CT300001901Medicare ID - Type UnspecifiedNVCI
CT300000627Medicare ID - Type UnspecifiedMRI
CT300000499Medicare ID - Type UnspecifiedNVRA
CT300002556Medicare ID - Type UnspecifiedDIS
CT001204213Medicaid