Healthcare Provider Details

I. General information

NPI: 1902852239
Provider Name (Legal Business Name): JAMIE DAVID SHUTTER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2006
Last Update Date: 12/19/2024
Certification Date: 12/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6250 N DURANGO DR
LAS VEGAS NV
89149-3916
US

IV. Provider business mailing address

PO BOX 25317 #207
TAMPA FL
33622-5317
US

V. Phone/Fax

Practice location:
  • Phone: 702-342-9990
  • Fax: 702-485-2372
Mailing address:
  • Phone: 813-286-0033
  • Fax: 813-282-1806

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License NumberD0091999
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number2011-00052
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License NumberMD036095
License Number StateDC
# 4
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License NumberR9435
License Number StateTX
# 5
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License NumberME 98596
License Number StateFL
# 6
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number25728
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: