Provider Demographics
NPI:1104927458
Name:SHUTACK, JOHN MICHAEL (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:MICHAEL
Last Name:SHUTACK
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:667 KINGSBOROUGH SQ STE 101
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23320-4999
Mailing Address - Country:US
Mailing Address - Phone:757-842-4481
Mailing Address - Fax:757-312-3135
Practice Address - Street 1:300 MEDICAL PKWY STE 206
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23320
Practice Address - Country:US
Practice Address - Phone:757-690-8990
Practice Address - Fax:757-198-6944
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2024-06-20
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
VA0101102740207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0101102740OtherMEDICAL LICENSE
GAP00359996OtherRAILROAD
GAP00359996OtherRAILROAD
GA202I148725Medicare UPIN