Provider Demographics
NPI:1104869312
Name:SHETTY, PURANCHANDER (MD)
Entity type:Individual
Prefix:
First Name:PURANCHANDER
Middle Name:
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:PO BOX 4459
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48504-0459
Mailing Address - Country:US
Mailing Address - Phone:810-424-4761
Mailing Address - Fax:810-424-4871
Practice Address - Street 1:HURLEY MEDICAL CENTER
Practice Address - Street 2:ONE HURLEY PLAZA, RADIOLOGY DEPT
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48503
Practice Address - Country:US
Practice Address - Phone:810-424-4761
Practice Address - Fax:810-424-4871
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010371122085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIB44791Medicare UPIN