Provider Demographics
NPI:1760645295
Name:SHETTY, SHUBHA PREMNATH (MD)
Entity Type:Individual
Prefix:DR
First Name:SHUBHA
Middle Name:PREMNATH
Last Name:SHETTY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:SHUBHA
Other - Middle Name:M
Other - Last Name:RAI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:4502 RIVERSTONE BLVD
Mailing Address - Street 2:STE 1003
Mailing Address - City:MISSOURI CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77459-5209
Mailing Address - Country:US
Mailing Address - Phone:713-798-1835
Mailing Address - Fax:
Practice Address - Street 1:4502 RIVERSTONE BLVD
Practice Address - Street 2:
Practice Address - City:MISSOURI CITY
Practice Address - State:TX
Practice Address - Zip Code:77459-5204
Practice Address - Country:US
Practice Address - Phone:281-778-9420
Practice Address - Fax:281-778-9422
Is Sole Proprietor?:No
Enumeration Date:2008-07-03
Last Update Date:2020-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN4096207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8L22196Medicare PIN