Provider Demographics
NPI:1912064395
Name:HUTTO, MARCUS
Entity Type:Individual
Prefix:
First Name:MARCUS
Middle Name:
Last Name:HUTTO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17391 HIGHWAY 65 S
Mailing Address - Street 2:
Mailing Address - City:DAMASCUS
Mailing Address - State:AR
Mailing Address - Zip Code:72039-8913
Mailing Address - Country:US
Mailing Address - Phone:501-514-4328
Mailing Address - Fax:
Practice Address - Street 1:851 YELLOWJACKET LN
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:AR
Practice Address - Zip Code:72031-6873
Practice Address - Country:US
Practice Address - Phone:501-745-6034
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-03
Last Update Date:2022-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AROTR1762171W00000X, 225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR148502721Medicaid