Healthcare Provider Details

I. General information

NPI: 1073742425
Provider Name (Legal Business Name): CREIGHTON E SHUTE D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/07/2009
Last Update Date: 09/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5750 JOHNSTON ST STE 101
LAFAYETTE LA
70503-5334
US

IV. Provider business mailing address

5750 JOHNSTON ST STE 101
LAFAYETTE LA
70503-5334
US

V. Phone/Fax

Practice location:
  • Phone: 337-703-0703
  • Fax: 337-703-0704
Mailing address:
  • Phone: 337-703-0703
  • Fax: 337-703-0704

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License NumberDO.000309
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberDO.000309
License Number StateLA
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberDO.000309
License Number StateLA
# 4
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberDO.000309
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: