Provider Demographics
NPI:1780838524
Name:SHATTUCK, ANTHONY (SOIDC)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:
Last Name:SHATTUCK
Suffix:
Gender:M
Credentials:SOIDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2D MARINE SPECIAL OPERATIONS BATTALION
Mailing Address - Street 2:PSC BOX 20183
Mailing Address - City:CAMP LEJEUNE
Mailing Address - State:NC
Mailing Address - Zip Code:28542
Mailing Address - Country:US
Mailing Address - Phone:910-450-7704
Mailing Address - Fax:
Practice Address - Street 1:2D MARINE SPECIAL OPERATIONS BATTALION
Practice Address - Street 2:PSC 20183
Practice Address - City:CAMP LEJEUNE
Practice Address - State:NC
Practice Address - Zip Code:28542
Practice Address - Country:US
Practice Address - Phone:910-450-7704
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-11-06
Last Update Date:2008-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman