Provider Demographics
NPI:1619914975
Name:SHETTY, DINAKARA B (MD)
Entity Type:Individual
Prefix:DR
First Name:DINAKARA
Middle Name:B
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 1:1719 RUSSELL PKWY
Mailing Address - Street 2:BUILDING #700
Mailing Address - City:WARNER ROBINS
Mailing Address - State:GA
Mailing Address - Zip Code:31088-5763
Mailing Address - Country:US
Mailing Address - Phone:478-328-0806
Mailing Address - Fax:478-328-1393
Practice Address - Street 1:1719 RUSSELL PKWY
Practice Address - Street 2:BLDG 700
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31088-5763
Practice Address - Country:US
Practice Address - Phone:478-328-0806
Practice Address - Fax:478-328-1393
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-02
Last Update Date:2008-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA042431207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00720948LMedicaid
GA11BDSRLMedicare ID - Type Unspecified
G36466Medicare UPIN