Provider Demographics
NPI:1689949448
Name:SHUTT, BRENNAN JOSEPH (DO)
Entity Type:Individual
Prefix:
First Name:BRENNAN
Middle Name:JOSEPH
Last Name:SHUTT
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3300 OAKDALE AVE N
Mailing Address - Street 2:
Mailing Address - City:ROBBINSDALE
Mailing Address - State:MN
Mailing Address - Zip Code:55422-2926
Mailing Address - Country:US
Mailing Address - Phone:763-520-5200
Mailing Address - Fax:763-581-4771
Practice Address - Street 1:3300 OAKDALE AVE N
Practice Address - Street 2:
Practice Address - City:ROBBINSDALE
Practice Address - State:MN
Practice Address - Zip Code:55422
Practice Address - Country:US
Practice Address - Phone:763-520-5200
Practice Address - Fax:763-581-4771
Is Sole Proprietor?:No
Enumeration Date:2012-03-13
Last Update Date:2019-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02004294A207R00000X
CA20A14186207R00000X
MN65224207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAVAD0000Medicare UPIN