Provider Demographics
NPI:1417980434
Name:CHETAN, SHASHI (MD)
Entity Type:Individual
Prefix:DR
First Name:SHASHI
Middle Name:
Last Name:CHETAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 40767
Mailing Address - Street 2:CREDENTIALING DEPARTMENT
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32203-0767
Mailing Address - Country:US
Mailing Address - Phone:904-376-3707
Mailing Address - Fax:904-391-5807
Practice Address - Street 1:820 PRUDENTIAL DR STE 304
Practice Address - Street 2:CREDENTIALING DEPARTMENT
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-8205
Practice Address - Country:US
Practice Address - Phone:904-346-3649
Practice Address - Fax:904-348-5627
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2015-02-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME91712207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL2711478-00Medicaid
FLP00364691OtherRAILROAD MEDICARE
FL2711478-00Medicaid
FLP00364691OtherRAILROAD MEDICARE