Provider Demographics
NPI:1730245333
Name:SHETTY, PHYLLIS (MD)
Entity type:Individual
Prefix:DR
First Name:PHYLLIS
Middle Name:
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 1:700 US RT 130 N
Mailing Address - Street 2:SUITE 203
Mailing Address - City:CINNAMINSON
Mailing Address - State:NJ
Mailing Address - Zip Code:08077
Mailing Address - Country:US
Mailing Address - Phone:856-829-9345
Mailing Address - Fax:856-829-0580
Practice Address - Street 1:130 GAITHER DR
Practice Address - Street 2:
Practice Address - City:MOUNT LAUREL
Practice Address - State:NJ
Practice Address - Zip Code:08054-1715
Practice Address - Country:US
Practice Address - Phone:856-722-7000
Practice Address - Fax:856-829-0580
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA03821300207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology