Provider Demographics
NPI:1417998832
Name:SHETTAR, SHASHIDHAR M (MD)
Entity Type:Individual
Prefix:DR
First Name:SHASHIDHAR
Middle Name:M
Last Name:SHETTAR
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 1:2500 N STATE ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4500
Mailing Address - Country:US
Mailing Address - Phone:601-984-6925
Mailing Address - Fax:601-984-5842
Practice Address - Street 1:2500 N STATE ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4500
Practice Address - Country:US
Practice Address - Phone:601-984-6925
Practice Address - Fax:601-984-5842
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2012-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS168682084P0800X, 2084S0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084S0012XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologySleep Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS260045973OtherPALMETTO GBA-RAILROAD MED
MS00122383Medicaid
MSP00462322OtherRR MEDICARE PTAN
MS512I260013Medicare PIN
MS260045973OtherPALMETTO GBA-RAILROAD MED
MSP00462322OtherRR MEDICARE PTAN
MSE89223Medicare UPIN