Provider Demographics
NPI:1568681401
Name:SHETTY, KADANDALE RAVINDRANATH (MD)
Entity Type:Individual
Prefix:DR
First Name:KADANDALE
Middle Name:RAVINDRANATH
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 1:8 DIXON AVE
Mailing Address - Street 2:
Mailing Address - City:AMITYVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11701-2808
Mailing Address - Country:US
Mailing Address - Phone:631-789-4433
Mailing Address - Fax:631-789-4761
Practice Address - Street 1:8 DIXON AVE
Practice Address - Street 2:
Practice Address - City:AMITYVILLE
Practice Address - State:NY
Practice Address - Zip Code:11701-2808
Practice Address - Country:US
Practice Address - Phone:631-789-4433
Practice Address - Fax:631-789-4761
Is Sole Proprietor?:No
Enumeration Date:2007-04-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY11050112084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY12040OtherHIP
NY566721Medicare ID - Type Unspecified
NY12040OtherHIP