Provider Demographics
NPI:1417021684
Name:SHTASEL, DERRI (MD)
Entity Type:Individual
Prefix:
First Name:DERRI
Middle Name:
Last Name:SHTASEL
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 1:15 PARKMAN ST, WAC 812
Mailing Address - Street 2:MASSACHUSETTS GENERAL HOSPITAL
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02114-1047
Mailing Address - Country:US
Mailing Address - Phone:617-643-4340
Mailing Address - Fax:
Practice Address - Street 1:15 PARKMAN ST, WAC 812
Practice Address - Street 2:MASSACHUSETTS GENERAL HOSPITAL
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114
Practice Address - Country:US
Practice Address - Phone:617-643-4340
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2009-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1583702084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAA28772Medicare ID - Type Unspecified