Provider Demographics
NPI:1831290980
Name:SHETH, BAKULA S (MD)
Entity Type:Individual
Prefix:
First Name:BAKULA
Middle Name:S
Last Name:SHETH
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 1:1001 TREVILIAN WAY
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40213-1545
Mailing Address - Country:US
Mailing Address - Phone:502-473-8704
Mailing Address - Fax:
Practice Address - Street 1:1001 TREVILIAN WAY
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40213-1545
Practice Address - Country:US
Practice Address - Phone:502-473-8704
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-25
Last Update Date:2012-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY22084207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64220841Medicaid
KY1427701Medicare ID - Type Unspecified
KYC75713Medicare UPIN