Provider Demographics
NPI:1104269265
Name:SHETTAR, VIGNESH (MD)
Entity type:Individual
Prefix:
First Name:VIGNESH
Middle Name:
Last Name:SHETTAR
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 1:280 CHESTNUT STREET
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01199-1001
Mailing Address - Country:US
Mailing Address - Phone:413-794-5700
Mailing Address - Fax:413-794-1629
Practice Address - Street 1:3300 MAIN STREET
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01107-1112
Practice Address - Country:US
Practice Address - Phone:413-794-7031
Practice Address - Fax:413-794-7133
Is Sole Proprietor?:No
Enumeration Date:2013-04-09
Last Update Date:2023-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI63353-20207R00000X
ORMD190317207RE0101X
MA1015064207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine