Healthcare Provider Details

I. General information

NPI: 1164410585
Provider Name (Legal Business Name): SUPRITHA A SHETTY M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2005
Last Update Date: 07/06/2023
Certification Date: 07/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3928 WASHINGTON RD STE 220
MC MURRAY PA
15317-2594
US

IV. Provider business mailing address

701 TECHNOLOGY DR STE 150
CANONSBURG PA
15317-9531
US

V. Phone/Fax

Practice location:
  • Phone: 724-941-8877
  • Fax: 724-941-4745
Mailing address:
  • Phone: 412-531-2902
  • Fax: 412-531-2948

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number20986
License Number StateWV
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD065791L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: