Provider Demographics
NPI:1255477725
Name:SHUTKO, CANDICE E
Entity Type:Individual
Prefix:
First Name:CANDICE
Middle Name:E
Last Name:SHUTKO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6431 FANNIN ST # 5.197
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77030-1501
Mailing Address - Country:US
Mailing Address - Phone:713-500-6200
Mailing Address - Fax:
Practice Address - Street 1:6431 FANNIN ST # 5.197
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-1501
Practice Address - Country:US
Practice Address - Phone:713-500-6200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2009-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM4541207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1880197 01Medicaid
TX8U4527OtherBLUE CROSS PROVIDER ID
TX8L1944Medicare PIN
TX8U4527OtherBLUE CROSS PROVIDER ID
8J5937Medicare PIN