Provider Demographics
NPI:1215040753
Name:JAYAPRAKASH SHETTY MD PA
Entity type:Organization
Organization Name:JAYAPRAKASH SHETTY MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAYAPRAKASH
Authorized Official - Middle Name:
Authorized Official - Last Name:SHETTY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:352-622-7755
Mailing Address - Street 1:1737A SE 28TH LOOP
Mailing Address - Street 2:
Mailing Address - City:OCALA
Mailing Address - State:FL
Mailing Address - Zip Code:34471-1079
Mailing Address - Country:US
Mailing Address - Phone:352-622-7755
Mailing Address - Fax:352-622-4021
Practice Address - Street 1:1737A SE 28TH LOOP
Practice Address - Street 2:
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34471-1079
Practice Address - Country:US
Practice Address - Phone:352-622-7755
Practice Address - Fax:352-622-4021
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-17
Last Update Date:2013-12-17
Deactivation Date:2007-10-04
Deactivation Code:
Reactivation Date:2008-12-23
Provider Licenses
StateLicense IDTaxonomies
FLME75985207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL008123700Medicaid
FLBC745Medicare PIN