Provider Demographics
NPI:1427037357
Name:SHETTY, DITHI A (MD)
Entity Type:Individual
Prefix:
First Name:DITHI
Middle Name:A
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 1:110 COACHMAN PLACE WEST
Mailing Address - Street 2:
Mailing Address - City:SYOSSET
Mailing Address - State:NY
Mailing Address - Zip Code:11791
Mailing Address - Country:US
Mailing Address - Phone:631-271-9151
Mailing Address - Fax:631-271-9155
Practice Address - Street 1:3500 FRANCISCAN WAY
Practice Address - Street 2:400
Practice Address - City:MICHIGAN CITY
Practice Address - State:IN
Practice Address - Zip Code:46360-0021
Practice Address - Country:US
Practice Address - Phone:516-965-1826
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-10
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI101547207RI0200X
NY2243611207RI0200X
IN01089055A207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02547097Medicaid
225AK1Medicare ID - Type Unspecified
NY02547097Medicaid