Healthcare Provider Details

I. General information

NPI: 1649264532
Provider Name (Legal Business Name): SHUBHRA M SHETTY M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2005
Last Update Date: 06/13/2024
Certification Date: 06/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 FRANKLIN AVE STE 3
SCRANTON PA
18503-1947
US

IV. Provider business mailing address

201 FRANKLIN AVE STE 3
SCRANTON PA
18503-1947
US

V. Phone/Fax

Practice location:
  • Phone: 570-800-7465
  • Fax: 570-800-7474
Mailing address:
  • Phone: 570-800-7465
  • Fax: 570-800-7474

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License NumberMD 059969L
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1758578
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: