Provider Demographics
NPI:1194216101
Name:ETTA, GINO SHWKAT (MD)
Entity Type:Individual
Prefix:
First Name:GINO
Middle Name:SHWKAT
Last Name:ETTA
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 1:27351 DEQUINDRE RD
Mailing Address - Street 2:
Mailing Address - City:MADISON HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48071-3487
Mailing Address - Country:US
Mailing Address - Phone:248-967-7661
Mailing Address - Fax:248-967-7876
Practice Address - Street 1:27351 DEQUINDRE RD
Practice Address - Street 2:
Practice Address - City:MADISON HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48071-3487
Practice Address - Country:US
Practice Address - Phone:248-967-7661
Practice Address - Fax:248-967-7876
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-24
Last Update Date:2021-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301501047207P00000X
OH35.141973207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine