Provider Demographics
NPI:1598327025
Name:SHTUTMAN, DAN (DO)
Entity Type:Individual
Prefix:
First Name:DAN
Middle Name:
Last Name:SHTUTMAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:DR
Other - First Name:DAN
Other - Middle Name:
Other - Last Name:SHTUTMAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DO
Mailing Address - Street 1:PO BOX 3630
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86003-3630
Mailing Address - Country:US
Mailing Address - Phone:480-375-0123
Mailing Address - Fax:
Practice Address - Street 1:2920 N 4TH ST
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86004-1816
Practice Address - Country:US
Practice Address - Phone:928-522-9400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-04
Last Update Date:2021-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZR3299390200000X
AZ008728207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program