Provider Demographics
NPI:1245319391
Name:SHETTY, SUMEET (MD)
Entity type:Individual
Prefix:
First Name:SUMEET
Middle Name:
Last Name:SHETTY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4820 GRIFFIN BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33908-2016
Mailing Address - Country:US
Mailing Address - Phone:239-208-6648
Mailing Address - Fax:855-462-3008
Practice Address - Street 1:3050 CHAMPION RING RD
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33905-5599
Practice Address - Country:US
Practice Address - Phone:239-313-2901
Practice Address - Fax:239-939-4811
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2023-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME91067207R00000X, 225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL270760800Medicaid
FL48938OtherBCBS
FL48938OtherBCBS
FL270760800Medicaid
FL48938ZMedicare PIN