Provider Demographics
NPI:1154429413
Name:MACHLEDT, JOHN HENDRIX JR (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:HENDRIX
Last Name:MACHLEDT
Suffix:JR
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 1:52 BEACH ROAD
Mailing Address - Street 2:STE 102
Mailing Address - City:FAIRFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06824
Mailing Address - Country:US
Mailing Address - Phone:203-259-7871
Mailing Address - Fax:203-254-2235
Practice Address - Street 1:52 BEACH ROAD
Practice Address - Street 2:STE 102
Practice Address - City:FAIRFIELD
Practice Address - State:CT
Practice Address - Zip Code:06824
Practice Address - Country:US
Practice Address - Phone:203-259-7871
Practice Address - Fax:203-254-2235
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT17242207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1172428Medicaid
CT1172428Medicaid