Provider Demographics
NPI:1871574913
Name:SHETTY, SUGANDH D (MD)
Entity type:Individual
Prefix:DR
First Name:SUGANDH
Middle Name:D
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 1:31157 WOODWARD AVE
Mailing Address - Street 2:
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48073-0926
Mailing Address - Country:US
Mailing Address - Phone:248-336-0123
Mailing Address - Fax:248-336-3190
Practice Address - Street 1:31157 WOODWARD AVE
Practice Address - Street 2:
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48073-0926
Practice Address - Country:US
Practice Address - Phone:248-336-0123
Practice Address - Fax:248-336-3190
Is Sole Proprietor?:No
Enumeration Date:2005-11-07
Last Update Date:2007-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301058781208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4202425Medicaid
MI4973480Medicaid
MISS058781OtherBCBSM LICENSE NUMBER
MI5809584OtherAETNA
MIG84304OtherHAP
MI131406OtherPREFERRED CARE CHOICES
MI3406338651OtherBCBSM INDIVIDUAL NUMBER
MIC7348OtherMCARE PIN
MI5809584OtherAETNA
MIG84304OtherHAP
MI4202425Medicaid