Provider Demographics
NPI:1487607065
Name:SHUTTARI, MIR (MD)
Entity type:Individual
Prefix:
First Name:MIR
Middle Name:
Last Name:SHUTTARI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 905
Mailing Address - Street 2:
Mailing Address - City:FALMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02541
Mailing Address - Country:US
Mailing Address - Phone:508-548-8989
Mailing Address - Fax:508-548-5789
Practice Address - Street 1:90 TER HEUN DR
Practice Address - Street 2:
Practice Address - City:FALMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02540-2533
Practice Address - Country:US
Practice Address - Phone:508-548-8574
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-18
Last Update Date:2009-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA52726207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA052726OtherTUFTS HEALTH
MA23598OtherHARVARD PILGRIM
MA0105961Medicaid
MA0105961Medicaid
F24382Medicare UPIN