Provider Demographics
NPI:1326297730
Name:HUTSON, SHANDEE MIQUELLE (MD)
Entity Type:Individual
Prefix:DR
First Name:SHANDEE
Middle Name:MIQUELLE
Last Name:HUTSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:8555 AERO DRIVE, SUITE 104
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123
Mailing Address - Country:US
Mailing Address - Phone:858-384-7828
Mailing Address - Fax:858-598-6344
Practice Address - Street 1:3003 HEALTH CENTER DRIVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92354-2804
Practice Address - Country:US
Practice Address - Phone:858-939-4198
Practice Address - Fax:858-939-4972
Is Sole Proprietor?:No
Enumeration Date:2008-09-10
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA1101972080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A901670Medicaid