Healthcare Provider Details

I. General information

NPI: 1104927458
Provider Name (Legal Business Name): JOHN MICHAEL SHUTACK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2006
Last Update Date: 06/20/2024
Certification Date: 06/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 MEDICAL PKWY STE 206
CHESAPEAKE VA
23320
US

IV. Provider business mailing address

667 KINGSBOROUGH SQ STE 101
CHESAPEAKE VA
23320-4999
US

V. Phone/Fax

Practice location:
  • Phone: 757-690-8990
  • Fax: 757-198-6944
Mailing address:
  • Phone: 757-842-4481
  • Fax: 757-312-3135

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number0101102740
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: