Provider Demographics
NPI:1679578983
Name:SHUTTA, JOHN A (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:A
Last Name:SHUTTA
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:PO BOX 37086
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21297-3086
Mailing Address - Country:US
Mailing Address - Phone:240-439-8812
Mailing Address - Fax:301-898-5230
Practice Address - Street 1:15 E FREDERICK ST
Practice Address - Street 2:
Practice Address - City:WALKERSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21793-8234
Practice Address - Country:US
Practice Address - Phone:301-898-5200
Practice Address - Fax:301-898-5230
Is Sole Proprietor?:No
Enumeration Date:2005-06-15
Last Update Date:2020-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0030020207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD378781800Medicaid
C49107Medicare UPIN
179FMedicare ID - Type Unspecified