Provider Demographics
NPI:1851461255
Name:SHETTY, MALA S (MD)
Entity Type:Individual
Prefix:DR
First Name:MALA
Middle Name:S
Last Name:SHETTY
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 1:51 S CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:PITTSFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01201-6178
Mailing Address - Country:US
Mailing Address - Phone:413-442-8393
Mailing Address - Fax:413-442-8332
Practice Address - Street 1:51 S CHURCH ST
Practice Address - Street 2:
Practice Address - City:PITTSFIELD
Practice Address - State:MA
Practice Address - Zip Code:01201-6132
Practice Address - Country:US
Practice Address - Phone:413-442-8393
Practice Address - Fax:413-442-8332
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-09
Last Update Date:2009-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA222509207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAA38311Medicare ID - Type Unspecified
MAI28244Medicare UPIN