Provider Demographics
NPI:1700810561
Name:SHETH, PRAVINA B (MD)
Entity Type:Individual
Prefix:
First Name:PRAVINA
Middle Name:B
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 1:2319 ST MATTHEWS ROAD
Mailing Address - Street 2:
Mailing Address - City:ORANGEBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29118
Mailing Address - Country:US
Mailing Address - Phone:803-536-1571
Mailing Address - Fax:803-536-1463
Practice Address - Street 1:2319 ST MATTHEWS ROAD
Practice Address - Street 2:
Practice Address - City:ORANGEBURG
Practice Address - State:SC
Practice Address - Zip Code:29118
Practice Address - Country:US
Practice Address - Phone:803-536-1571
Practice Address - Fax:803-536-1463
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2021-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20210363502084P0800X
SCSC79262084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC079266Medicaid
C602363345Medicare PIN
C60236Medicare UPIN