Provider Demographics
NPI:1538128186
Name:SHUTT, BRYCE C (MD)
Entity type:Individual
Prefix:DR
First Name:BRYCE
Middle Name:C
Last Name:SHUTT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:BRYCE
Other - Middle Name:C
Other - Last Name:SHUTT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:2400 AMBASSADOR DR
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76712-9702
Mailing Address - Country:US
Mailing Address - Phone:254-756-4457
Mailing Address - Fax:254-756-1718
Practice Address - Street 1:2400 AMBASSADOR DR
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76712-9702
Practice Address - Country:US
Practice Address - Phone:254-756-4457
Practice Address - Fax:254-756-1718
Is Sole Proprietor?:No
Enumeration Date:2006-03-22
Last Update Date:2023-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ2330174400000X, 207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX161488501Medicaid
TX00876RMedicare ID - Type UnspecifiedGROUP MEDICARE NUMBER
TX161488501Medicaid