Provider Demographics
NPI:1598913279
Name:SHAKER, CLAYTON (MD)
Entity type:Individual
Prefix:
First Name:CLAYTON
Middle Name:
Last Name:SHAKER
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 549
Mailing Address - Street 2:
Mailing Address - City:IRON MOUNTAIN
Mailing Address - State:MI
Mailing Address - Zip Code:49801-0549
Mailing Address - Country:US
Mailing Address - Phone:906-774-1313
Mailing Address - Fax:906-776-5639
Practice Address - Street 1:1711 S STEPHENSON AVE STE 115
Practice Address - Street 2:
Practice Address - City:IRON MOUNTAIN
Practice Address - State:MI
Practice Address - Zip Code:49801-3648
Practice Address - Country:US
Practice Address - Phone:906-776-5955
Practice Address - Fax:906-228-0202
Is Sole Proprietor?:No
Enumeration Date:2008-09-05
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301100058207R00000X, 207RC0000X
IL125051889207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0220132OtherBCBS PIN
MI0220132OtherBCBS PIN