Provider Demographics
NPI:1255547717
Name:DUTKA, MICHAEL VINCENT (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:VINCENT
Last Name:DUTKA
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 1:3625 QUAKERBRIDGE RD
Mailing Address - Street 2:#5B
Mailing Address - City:HAMILTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08619-1268
Mailing Address - Country:US
Mailing Address - Phone:609-689-1600
Mailing Address - Fax:
Practice Address - Street 1:2501 KUSER RD
Practice Address - Street 2:
Practice Address - City:HAMILTON
Practice Address - State:NJ
Practice Address - Zip Code:08691-3386
Practice Address - Country:US
Practice Address - Phone:609-585-8800
Practice Address - Fax:609-585-1825
Is Sole Proprietor?:No
Enumeration Date:2007-05-14
Last Update Date:2023-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA082642002085R0202X
NY2746412085R0202X
PAMD4255822085R0202X
DEC1-00095042085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03406851Medicaid
PA102108356Medicaid
NJ0158259Medicaid
PA125125Medicare PIN
NY03406851Medicaid
NJ124893Medicare PIN
DE198773Medicare PIN
PA102108356Medicaid