Provider Demographics
NPI:1972552412
Name:LUTKEVICH, CONNIE M (MD)
Entity type:Individual
Prefix:DR
First Name:CONNIE
Middle Name:M
Last Name:LUTKEVICH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:35 MEDICAL CENTER PKWY
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:ME
Mailing Address - Zip Code:04330-8160
Mailing Address - Country:US
Mailing Address - Phone:207-621-4680
Mailing Address - Fax:207-622-4085
Practice Address - Street 1:35 MEDICAL CENTER PKWY
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:ME
Practice Address - Zip Code:04330-8160
Practice Address - Country:US
Practice Address - Phone:207-621-4680
Practice Address - Fax:207-622-4085
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2021-08-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN45784208600000X
MEMD24966208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN580076500Medicaid