Provider Demographics
NPI:1932169620
Name:SHETTY, JAGADEESHA N (MD)
Entity type:Individual
Prefix:
First Name:JAGADEESHA
Middle Name:N
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 1:120 IRMC DR
Mailing Address - Street 2:SUITE160
Mailing Address - City:INDIANA
Mailing Address - State:PA
Mailing Address - Zip Code:15701-3674
Mailing Address - Country:US
Mailing Address - Phone:724-465-2676
Mailing Address - Fax:724-349-1830
Practice Address - Street 1:120 IRMC DR
Practice Address - Street 2:SUITE160
Practice Address - City:INDIANA
Practice Address - State:PA
Practice Address - Zip Code:15701-3674
Practice Address - Country:US
Practice Address - Phone:724-465-2676
Practice Address - Fax:724-349-1830
Is Sole Proprietor?:No
Enumeration Date:2006-03-25
Last Update Date:2016-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD064511L2081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PACI1160OtherRAILROAD MEDICARE
PA0016948000002Medicaid
PA0016948000002Medicaid
PACI1160OtherRAILROAD MEDICARE