Provider Demographics
NPI:1609944610
Name:SHUTE, GARY DEAN (OD, FAAO)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:DEAN
Last Name:SHUTE
Suffix:
Gender:M
Credentials:OD, FAAO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3945 1ST AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-3015
Mailing Address - Country:US
Mailing Address - Phone:619-295-4194
Mailing Address - Fax:619-295-4930
Practice Address - Street 1:3945 1ST AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-3015
Practice Address - Country:US
Practice Address - Phone:619-295-4194
Practice Address - Fax:619-295-4930
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2008-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA8857T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0088570Medicaid
CAOP8857Medicare PIN
CASD0088570Medicaid