MEDICARE: DAYANANDA MULUR SHETTY MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Y00000X	Otolaryngology Physician	01026607A	IN
2	207Y00000X	Otolaryngology Physician	ME86870	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	91107713	OTHER	IN	BCBS
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	49504600121	OTHER		AMA

General Provider Information

NPI Number	:	1366504342
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DAYANANDA MULUR SHETTY MD

Provider Business Mailing Address
First Line	:	9831 DEL WEBB PARKWAY
Second Line	:	#2305
City	:	JACKSONVILLE
State	:	FL
Zip	:	32256-5807
Country	:	US
Telephone Number	:	904-519-6575
Fax Number	:	904-519-6575

Provider Business Practice Location Address
First Line	:	9831 DEL WEBB PARKWAY
Second Line	:	#2305
City	:	JACKSONVILLE
State	:	FL
Zip	:	32256-5807
Country	:	US
Telephone Number	:	904-519-6575
Fax Number	:	904-519-6575

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/15/2006
Last Update Date	:	07/08/2007

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