Provider Demographics
NPI:1497767461
Name:DUKEHART, MATTHEW ROBERT (MD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:ROBERT
Last Name:DUKEHART
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 1:58 SOMERS HILL CIR
Mailing Address - Street 2:
Mailing Address - City:SOMERS
Mailing Address - State:CT
Mailing Address - Zip Code:06071-1927
Mailing Address - Country:US
Mailing Address - Phone:860-749-1210
Mailing Address - Fax:
Practice Address - Street 1:175 WEST RD
Practice Address - Street 2:SUITE 200
Practice Address - City:ELLINGTON
Practice Address - State:CT
Practice Address - Zip Code:06029-3730
Practice Address - Country:US
Practice Address - Phone:860-375-9122
Practice Address - Fax:860-375-9133
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2012-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT033860208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001338608Medicaid
CTF38722Medicare UPIN
CT001338608Medicaid