Basic Information
| Provider Information | |||||||||
| NPI: | 1255547717 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DUTKA | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | VINCENT | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3625 QUAKERBRIDGE RD | ||||||||
| Address2: | #5B | ||||||||
| City: | HAMILTON | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 086191268 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6096891600 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2501 KUSER RD | ||||||||
| Address2: | |||||||||
| City: | HAMILTON | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 086913386 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6095858800 | ||||||||
| FaxNumber: | 6095851825 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/14/2007 | ||||||||
| LastUpdateDate: | 03/17/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | MD425582 | PA | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 25MA08264200 | NJ | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | C1-0009504 | DE | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 274641 | NY | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 0158259 | 05 | NJ | MEDICAID | 102108356 | 05 | PA | MEDICAID | 03406851 | 05 | NY | MEDICAID |