Healthcare Provider Details

I. General information

NPI: 1114923729
Provider Name (Legal Business Name): JOHN A SHUTTA, MD, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/28/2005
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 E FREDERICK ST
WALKERSVILLE MD
21793-8234
US

IV. Provider business mailing address

15 E FREDERICK ST PO BOX 310
WALKERSVILLE MD
21793-8234
US

V. Phone/Fax

Practice location:
  • Phone: 301-898-5200
  • Fax: 301-898-5230
Mailing address:
  • Phone: 301-898-5200
  • Fax: 301-898-5230

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateMD

VIII. Authorized Official

Name: JOHN A SHUTTA
Title or Position: PRESIDENT
Credential: MD
Phone: 301-898-5200