Provider Demographics
NPI:1770770406
Name:SHETTY, VIJAY SHRIDHARA (MD)
Entity type:Individual
Prefix:DR
First Name:VIJAY
Middle Name:SHRIDHARA
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 1:20 LEPARC COURT
Mailing Address - Street 2:
Mailing Address - City:WEST WINDSOR
Mailing Address - State:NJ
Mailing Address - Zip Code:08550
Mailing Address - Country:US
Mailing Address - Phone:609-936-9737
Mailing Address - Fax:
Practice Address - Street 1:4802 10TH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11219
Practice Address - Country:US
Practice Address - Phone:718-283-8344
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-26
Last Update Date:2013-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY60-242933207R00000X
NY242933-1207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease