Basic Information
| Provider Information | |||||||||
| NPI: | 1104927458 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHUTACK | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | MICHAEL | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 667 KINGSBOROUGH SQ STE 101 | ||||||||
| Address2: | |||||||||
| City: | CHESAPEAKE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 233204999 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7576908990 | ||||||||
| FaxNumber: | 7572779939 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 MEDICAL PKWY STE 206 | ||||||||
| Address2: | |||||||||
| City: | CHESAPEAKE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 23320 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7576908990 | ||||||||
| FaxNumber: | 7572779939 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/26/2006 | ||||||||
| LastUpdateDate: | 05/07/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207T00000X | 0101102740 | VA | Y | Allopathic & Osteopathic Physicians | Neurological Surgery |
ID Information
| ID | Type | State | Issuer | Description | 0101102740 | 01 | VA | MEDICAL LICENSE | OTHER |