Provider Demographics
NPI:1548267958
Name:SHETTY, AMITA SADASHIV (MD)
Entity type:Individual
Prefix:
First Name:AMITA
Middle Name:SADASHIV
Last Name:SHETTY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1638 OWEN DR
Mailing Address - Street 2:ATTN: MANAGED CARE PLANNING
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28304-3424
Mailing Address - Country:US
Mailing Address - Phone:910-615-6949
Mailing Address - Fax:910-615-9761
Practice Address - Street 1:3308 MELROSE RD
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-1604
Practice Address - Country:US
Practice Address - Phone:910-615-3200
Practice Address - Fax:910-615-3201
Is Sole Proprietor?:No
Enumeration Date:2005-06-30
Last Update Date:2014-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC009700753207R00000X
NC9700753207RS0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC891173EMedicaid
NC1173EOtherBCBS
NC2249087BMedicare ID - Type Unspecified
NC891173EMedicaid