Healthcare Provider Details

I. General information

NPI: 1245209832
Provider Name (Legal Business Name): KETAN K SHETH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/16/2006
Last Update Date: 07/08/2024
Certification Date: 07/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1345 UNITY PL SUITE 145A
LAFAYETTE IN
47905-5760
US

IV. Provider business mailing address

PO BOX 4699
LAFAYETTE IN
47903-4699
US

V. Phone/Fax

Practice location:
  • Phone: 765-446-5040
  • Fax: 765-446-5041
Mailing address:
  • Phone: 765-449-2732
  • Fax: 765-449-1196

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number01040024A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number01040024A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: