Provider Demographics
NPI:1841383924
Name:SHUAYTO, MARWAN IBRAHIM (MD)
Entity Type:Individual
Prefix:
First Name:MARWAN
Middle Name:IBRAHIM
Last Name:SHUAYTO
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 1:1201 STONE ST
Mailing Address - Street 2:SUITE 8
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060-3563
Mailing Address - Country:US
Mailing Address - Phone:810-989-0000
Mailing Address - Fax:810-989-5266
Practice Address - Street 1:1201 STONE ST
Practice Address - Street 2:SUITE 8
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-3563
Practice Address - Country:US
Practice Address - Phone:810-989-0000
Practice Address - Fax:810-989-5266
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2012-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL000275922084N0400X
MI43010870252084N0400X
MI53150525522084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1841383924Medicaid
I67576Medicare UPIN