Provider Demographics
NPI:1942307814
Name:SUTTON, SHELLEY OLIVIA (MD)
Entity Type:Individual
Prefix:DR
First Name:SHELLEY
Middle Name:OLIVIA
Last Name:SUTTON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6316 EL PASO ST
Mailing Address - Street 2:
Mailing Address - City:WHITESTOWN
Mailing Address - State:IN
Mailing Address - Zip Code:46075-5503
Mailing Address - Country:US
Mailing Address - Phone:317-847-8298
Mailing Address - Fax:
Practice Address - Street 1:2045 FAIRMONT DR
Practice Address - Street 2:
Practice Address - City:SAN LEANDRO
Practice Address - State:CA
Practice Address - Zip Code:94578-1088
Practice Address - Country:US
Practice Address - Phone:510-667-7540
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2022-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010933272084P0804X
MO20030122622084P0804X
CAC536162084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO208800300Medicaid
MO177466OtherBLUE CROSS BLUE SHIELD
MO208800300Medicaid
MO208800300Medicaid