Healthcare Provider Details

I. General information

NPI: 1427037357
Provider Name (Legal Business Name): DITHI A SHETTY MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/10/2006
Last Update Date: 10/20/2025
Certification Date: 10/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 N BEAVER ST
FLAGSTAFF AZ
86001-3118
US

IV. Provider business mailing address

110 COACHMAN PLACE WEST
SYOSSET NY
11791
US

V. Phone/Fax

Practice location:
  • Phone: 928-773-2200
  • Fax:
Mailing address:
  • Phone: 631-271-9151
  • Fax: 631-271-9155

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number2024-01959
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number76890
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number2243611
License Number StateNY
# 4
Primary TaxonomyN
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number84182
License Number StateWI
# 5
Primary TaxonomyN
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number01089055A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: