Provider Demographics
NPI:1801974696
Name:SHUTE, MICHELLE (MD)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:SHUTE
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 1:2850 TELEGRAPH AVE
Mailing Address - Street 2:SUITE #130
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94705-1159
Mailing Address - Country:US
Mailing Address - Phone:510-204-8110
Mailing Address - Fax:510-843-0804
Practice Address - Street 1:2850 TELEGRAPH AVE
Practice Address - Street 2:SUITE #130
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94705-1159
Practice Address - Country:US
Practice Address - Phone:510-204-8110
Practice Address - Fax:510-843-0804
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2013-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG79558207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G795580Medicaid
G09683Medicare UPIN
00G795580Medicare ID - Type Unspecified