Provider Demographics
NPI:1215959416
Name:SHETTY, HARI (MD)
Entity type:Individual
Prefix:
First Name:HARI
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 1:44 AMBASSADOR LN
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10309-1996
Mailing Address - Country:US
Mailing Address - Phone:718-317-1813
Mailing Address - Fax:
Practice Address - Street 1:2601 OCEAN PKWY
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11235-7745
Practice Address - Country:US
Practice Address - Phone:718-616-4408
Practice Address - Fax:718-616-4105
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY237734207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02704281Medicaid
NY0948T1Medicare ID - Type Unspecified
NY02704281Medicaid