Healthcare Provider Details

I. General information

NPI: 1700844271
Provider Name (Legal Business Name): JAYAPRAKASH B SHETTY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2006
Last Update Date: 07/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

132 MANSFIELD AVENUE
WILLIMANTIC CT
06226-2027
US

IV. Provider business mailing address

1007 N MAIN STRET
DAYVILLE CT
06241-0839
US

V. Phone/Fax

Practice location:
  • Phone: 860-456-2261
  • Fax: 860-450-1357
Mailing address:
  • Phone: 860-774-2020
  • Fax: 860-779-5437

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number25058
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: