1366504342 NPI number — DAYANANDA MULUR SHETTY MD

Table of content: DAYANANDA MULUR SHETTY MD (NPI 1366504342)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366504342 NPI number — DAYANANDA MULUR SHETTY MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHETTY
Provider First Name:
DAYANANDA
Provider Middle Name:
MULUR
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

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:
1366504342
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9831 DEL WEBB PARKWAY
Provider Second Line Business Mailing Address:
#2305
Provider Business Mailing Address City Name:
JACKSONVILLE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32256-5807
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-519-6575
Provider Business Mailing Address Fax Number:
904-519-6575

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9831 DEL WEBB PARKWAY
Provider Second Line Business Practice Location Address:
#2305
Provider Business Practice Location Address City Name:
JACKSONVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32256-5807
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-519-6575
Provider Business Practice Location Address Fax Number:
904-519-6575
Provider Enumeration Date:
12/15/2006

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: 207Y00000X , with the licence number:  01026607A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Y00000X , with the licence number: ME86870 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 91107713 . This is a "BCBS" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 100141560A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 49504600121 . This is a "AMA" identifier . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com