Provider Demographics
NPI:1932192788
Name:SHETTY, RITU KHANNA (MD)
Entity Type:Individual
Prefix:
First Name:RITU
Middle Name:KHANNA
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 1:6400 SHAFER CT STE 700
Mailing Address - Street 2:
Mailing Address - City:ROSEMONT
Mailing Address - State:IL
Mailing Address - Zip Code:60018-4989
Mailing Address - Country:US
Mailing Address - Phone:346-376-1702
Mailing Address - Fax:224-532-2780
Practice Address - Street 1:11675 GREAT OAKS WAY STE 310
Practice Address - Street 2:
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30022-2402
Practice Address - Country:US
Practice Address - Phone:404-250-4950
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-26
Last Update Date:2022-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0076820207Q00000X
GAH84123207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1117449Medicaid
WA0174035OtherL&I
WAP00017706OtherRR MEDICARE
WA0174035OtherL&I
WA1117449Medicaid
WAG8860324Medicare PIN