Provider Demographics
NPI:1083786768
Name:SHUTTLEWORTH, MARK READ (DC)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:READ
Last Name:SHUTTLEWORTH
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:665 E PASS RD STE 3
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39507
Mailing Address - Country:US
Mailing Address - Phone:228-896-3002
Mailing Address - Fax:228-897-1417
Practice Address - Street 1:665 EAST PASS RD STE 3
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39507
Practice Address - Country:US
Practice Address - Phone:228-896-3002
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2018-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS0753111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00115351Medicaid
MS00115351Medicaid
MS350000050Medicare ID - Type Unspecified