Provider Demographics
NPI:1770501413
Name:SHETTY, MANGALA J (MD)
Entity Type:Individual
Prefix:DR
First Name:MANGALA
Middle Name:J
Last Name:SHETTY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:11350 MCCORMICK RD
Mailing Address - Street 2:EXECUTIVE PLAZA 1, STE. 501
Mailing Address - City:HUNT VALLEY
Mailing Address - State:MD
Mailing Address - Zip Code:21031-4002
Mailing Address - Country:US
Mailing Address - Phone:703-914-8000
Mailing Address - Fax:631-329-6951
Practice Address - Street 1:1737A SE 28TH LOOP
Practice Address - Street 2:
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34471
Practice Address - Country:US
Practice Address - Phone:352-622-1840
Practice Address - Fax:352-622-0157
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2022-01-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME75986207L00000X, 208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL254258700Medicaid
FL43570Medicare PIN
G70835Medicare UPIN