Basic Information
Provider Information | |||||||||
NPI: | 1598327025 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SHTUTMAN | ||||||||
FirstName: | DAN | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | DO | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | SHTUTMAN | ||||||||
OtherFirstName: | DAN | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | DO | ||||||||
OtherLastNameType: | 2 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 3630 | ||||||||
Address2: |   | ||||||||
City: | FLAGSTAFF | ||||||||
State: | AZ | ||||||||
PostalCode: | 860033630 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4803750123 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2920 N 4TH ST | ||||||||
Address2: |   | ||||||||
City: | FLAGSTAFF | ||||||||
State: | AZ | ||||||||
PostalCode: | 860041816 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9285229400 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/04/2019 | ||||||||
LastUpdateDate: | 05/07/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 05/07/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | R3299 | AZ | N |   | Student, Health Care | Student in an Organized Health Care Education/Training Program |   | 207Q00000X | 008728 | AZ | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
No ID Information.