Provider Demographics
NPI:1649477035
Name:SHETTY, ANITA KANITHAHALLI (MD)
Entity type:Individual
Prefix:DR
First Name:ANITA
Middle Name:KANITHAHALLI
Last Name:SHETTY
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:5730 GLENRIDGE DR STE T100
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30328-5747
Mailing Address - Country:US
Mailing Address - Phone:404-939-9220
Mailing Address - Fax:470-312-2157
Practice Address - Street 1:835 COGBURN AVE NW
Practice Address - Street 2:SUITE 100
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-1031
Practice Address - Country:US
Practice Address - Phone:770-422-5557
Practice Address - Fax:770-422-5456
Is Sole Proprietor?:No
Enumeration Date:2007-06-28
Last Update Date:2018-01-30
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Provider Licenses
StateLicense IDTaxonomies
GA068558207N00000X
IL125.055689207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA068558OtherGEORGIA STATE MEDICAL LICENSE
GA202I070418Medicare PIN
GA002445OtherRTP NUMBER