Provider Demographics
NPI:1811332844
Name:SHUTAK, CHASE WALTER (MD, MPH)
Entity type:Individual
Prefix:DR
First Name:CHASE
Middle Name:WALTER
Last Name:SHUTAK
Suffix:
Gender:M
Credentials:MD, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2530 CHICAGO AVE STE 390
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55404-4289
Mailing Address - Country:US
Mailing Address - Phone:612-813-6107
Mailing Address - Fax:
Practice Address - Street 1:2530 CHICAGO AVE STE 309
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55404-4289
Practice Address - Country:US
Practice Address - Phone:612-813-6107
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-03
Last Update Date:2017-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN60339208000000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics