Provider Demographics
NPI:1801884556
Name:SHETTY, ATUL (MD)
Entity type:Individual
Prefix:
First Name:ATUL
Middle Name:
Last Name:SHETTY
Suffix:
Gender:M
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:PO BOX 2154
Mailing Address - Street 2:
Mailing Address - City:WEIRTON
Mailing Address - State:WV
Mailing Address - Zip Code:26062-1354
Mailing Address - Country:US
Mailing Address - Phone:304-723-5400
Mailing Address - Fax:304-723-5401
Practice Address - Street 1:485 COLLIERS WAY
Practice Address - Street 2:SUITE M
Practice Address - City:WEIRTON
Practice Address - State:WV
Practice Address - Zip Code:26062-5012
Practice Address - Country:US
Practice Address - Phone:304-723-5400
Practice Address - Fax:304-723-5401
Is Sole Proprietor?:No
Enumeration Date:2005-10-07
Last Update Date:2008-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV19885207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0017525380003Medicaid
OH2151684Medicaid
WV60000159000Medicaid
PA0017525380003Medicaid
PA030350QS6Medicare PIN
WV60000159000Medicaid
OH2151684Medicaid
WV0880985Medicare PIN