Provider Demographics
NPI:1558361444
Name:SHATTUCK, THEODORE G (MD)
Entity Type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:G
Last Name:SHATTUCK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:69 ALLEN ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:RUTLAND
Mailing Address - State:VT
Mailing Address - Zip Code:05701-4564
Mailing Address - Country:US
Mailing Address - Phone:802-775-3314
Mailing Address - Fax:802-775-9617
Practice Address - Street 1:69 ALLEN ST
Practice Address - Street 2:SUITE 4
Practice Address - City:RUTLAND
Practice Address - State:VT
Practice Address - Zip Code:05701-4564
Practice Address - Country:US
Practice Address - Phone:802-775-3314
Practice Address - Fax:802-775-9617
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT042-0006143207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VTOOO9206Medicaid
VTSHVT9206Medicare ID - Type Unspecified
VTOOO9206Medicaid