1548267958 NPI number — AMITA SADASHIV SHETTY M.D.

Table of content: DR. FRANK M WU DO (NPI 1750542338)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548267958 NPI number — AMITA SADASHIV SHETTY M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHETTY
Provider First Name:
AMITA
Provider Middle Name:
SADASHIV
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1548267958
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/27/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1638 OWEN DR
Provider Second Line Business Mailing Address:
ATTN: MANAGED CARE PLANNING
Provider Business Mailing Address City Name:
FAYETTEVILLE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28304-3424
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
910-615-6949
Provider Business Mailing Address Fax Number:
910-615-9761

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3308 MELROSE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FAYETTEVILLE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28304-1604
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-615-3200
Provider Business Practice Location Address Fax Number:
910-615-3201
Provider Enumeration Date:
06/30/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  009700753 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RS0012X , with the licence number: 9700753 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 891173E , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1173E . This is a "BCBS" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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