=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578506622
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TEENA SHETTY MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/14/2006
-----------------------------------------------------
Last Update Date | 12/31/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 535 E 70TH ST
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10021-4823
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-774-2318
-----------------------------------------------------
Fax | 212-249-9185
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 29234
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10087-9234
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-774-2138
-----------------------------------------------------
Fax | 631-329-6951
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084N0400X
-----------------------------------------------------
Taxonomy Name | Neurology Physician
-----------------------------------------------------
License Number | 223845
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------