Provider Demographics
NPI:1578501052
Name:SHUT, VLADISLAV (DPT)
Entity Type:Individual
Prefix:
First Name:VLADISLAV
Middle Name:
Last Name:SHUT
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9201 W SUNSET BLVD STE M120
Mailing Address - Street 2:
Mailing Address - City:WEST HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90069-3714
Mailing Address - Country:US
Mailing Address - Phone:310-246-1050
Mailing Address - Fax:
Practice Address - Street 1:9201 W SUNSET BLVD STE M120
Practice Address - Street 2:
Practice Address - City:WEST HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:90069-3714
Practice Address - Country:US
Practice Address - Phone:310-246-1050
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-04
Last Update Date:2018-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT32430208100000X
225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA205559183OtherTAX ID
CAPT32430OtherLICENSE