Provider Demographics
NPI:1538155627
Name:SATHEESH K SHETTY MD PC
Entity type:Organization
Organization Name:SATHEESH K SHETTY MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SATHEESH
Authorized Official - Middle Name:K
Authorized Official - Last Name:SHETTY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:405-834-4274
Mailing Address - Street 1:PO BOX 21891
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73156-1891
Mailing Address - Country:US
Mailing Address - Phone:405-834-4274
Mailing Address - Fax:405-748-4694
Practice Address - Street 1:3048 SW 89TH ST
Practice Address - Street 2:SUITE -A
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73159-6385
Practice Address - Country:US
Practice Address - Phone:405-834-4274
Practice Address - Fax:405-748-4694
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-23
Last Update Date:2014-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK18820207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100746630AMedicaid
OK495889260002OtherBCBS
OK100746630AMedicaid