Provider Demographics
NPI:1598830234
Name:SHUTKIN, PETER M (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:M
Last Name:SHUTKIN
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 1:173 EAST AVENUE
Mailing Address - Street 2:
Mailing Address - City:NEW CANAAN
Mailing Address - State:CT
Mailing Address - Zip Code:06840
Mailing Address - Country:US
Mailing Address - Phone:203-972-4255
Mailing Address - Fax:203-801-2126
Practice Address - Street 1:173 EAST AVENUE
Practice Address - Street 2:
Practice Address - City:NEW CANAAN
Practice Address - State:CT
Practice Address - Zip Code:06840
Practice Address - Country:US
Practice Address - Phone:203-972-4255
Practice Address - Fax:203-801-2126
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT012542207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
9519598002OtherCIGNA
00112542600OtherHUSKEY
4125199OtherAETNA
ZPZ97OtherOXFORD
0000121773201OtherUHC
01002542CT02OtherANTHEM BC
4125199OtherAETNA