Basic Information
| Provider Information | |||||||||
| NPI: | 1760645295 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHETTY | ||||||||
| FirstName: | SHUBHA | ||||||||
| MiddleName: | PREMNATH | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | RAI | ||||||||
| OtherFirstName: | SHUBHA | ||||||||
| OtherMiddleName: | M | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4502 RIVERSTONE BLVD | ||||||||
| Address2: | STE 1003 | ||||||||
| City: | MISSOURI CITY | ||||||||
| State: | TX | ||||||||
| PostalCode: | 774595209 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7137981835 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4502 RIVERSTONE BLVD | ||||||||
| Address2: | |||||||||
| City: | MISSOURI CITY | ||||||||
| State: | TX | ||||||||
| PostalCode: | 774595204 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2817789420 | ||||||||
| FaxNumber: | 2817789422 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/03/2008 | ||||||||
| LastUpdateDate: | 09/24/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | N4096 | TX | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.