Provider Demographics
NPI:1659306892
Name:SHETTY-DAS, RENUKA (MD)
Entity Type:Individual
Prefix:
First Name:RENUKA
Middle Name:
Last Name:SHETTY-DAS
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:PO BOX 27842
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10087-7842
Mailing Address - Country:US
Mailing Address - Phone:718-670-1651
Mailing Address - Fax:516-437-4167
Practice Address - Street 1:18219 HORACE HARDING EXPY
Practice Address - Street 2:
Practice Address - City:FRESH MEADOWS
Practice Address - State:NY
Practice Address - Zip Code:11365-2242
Practice Address - Country:US
Practice Address - Phone:718-670-2903
Practice Address - Fax:516-437-4167
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2022-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY209331207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01890477Medicaid
NY110192596Medicare PIN
NY01890477Medicaid
NYG87618Medicare UPIN