Provider Demographics
NPI:1134109135
Name:SHUTTLEWORTH, WILLIAM EDWARD (MD)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:EDWARD
Last Name:SHUTTLEWORTH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1008 MEDICAL CENTER DR
Mailing Address - Street 2:STE A
Mailing Address - City:POWDERLY
Mailing Address - State:KY
Mailing Address - Zip Code:42367-5463
Mailing Address - Country:US
Mailing Address - Phone:270-338-9653
Mailing Address - Fax:270-338-1756
Practice Address - Street 1:1008 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:POWDERLY
Practice Address - State:KY
Practice Address - Zip Code:42367-5463
Practice Address - Country:US
Practice Address - Phone:270-338-9653
Practice Address - Fax:270-338-1756
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-18
Last Update Date:2008-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY17855208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64178551Medicaid
KYC69069Medicare UPIN
KY1321601Medicare PIN