Provider Demographics
NPI:1285798447
Name:SHATTUCK, THADDEUS T (MD)
Entity type:Individual
Prefix:DR
First Name:THADDEUS
Middle Name:T
Last Name:SHATTUCK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:165 LANCASTER ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04101-2406
Mailing Address - Country:US
Mailing Address - Phone:207-874-1030
Mailing Address - Fax:207-874-1044
Practice Address - Street 1:330 SABATTUS ST STE A
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ME
Practice Address - Zip Code:04240-5553
Practice Address - Country:US
Practice Address - Phone:207-777-8959
Practice Address - Fax:207-753-3093
Is Sole Proprietor?:No
Enumeration Date:2006-12-21
Last Update Date:2024-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMD185272084S0012X
ME0185272084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084S0012XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologySleep Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME00178310Medicare PIN