Provider Demographics
NPI:1912341934
Name:SHETH, SUDIP MANOJ (MD)
Entity Type:Individual
Prefix:
First Name:SUDIP
Middle Name:MANOJ
Last Name:SHETH
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 1:701 W 5TH ST STE 3142
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79763-4206
Mailing Address - Country:US
Mailing Address - Phone:432-703-5310
Mailing Address - Fax:432-335-5354
Practice Address - Street 1:701 W 5TH ST
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79763
Practice Address - Country:US
Practice Address - Phone:432-703-5310
Practice Address - Fax:432-335-5354
Is Sole Proprietor?:No
Enumeration Date:2013-04-21
Last Update Date:2019-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXS0089208000000X, 2080N0001X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program