Mitchell Douglas Duckworth, DDS

Key facts

NPI

1649530601

Entity type

Individual (NPI type 1)

Primary specialty

Student in an Organized Health Care Education/Training Program 390200000X

Practice address

Stony Brook University Hospital Dept of
Stony Brook, NY 11794-8711

Phone

(631) 444-2557

Fax

(631) 444-6013

NPI assigned

May 24, 2012

Sex

Male

Sole proprietor

No

Organizations & group practices 6

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Family Surgical Suite Ambulatory Surgical Clinic/Center · West Jordan, UT · NPI 1508040221
  Medicare reassignment NPD UT
• Care Anesthesia Dental Anesthesiology · Holladay, UT · NPI 1134095151
  NPD Authorized official DENTAL ANESTHESIOLOGY
• Care Anesthesia Dental Anesthesiology · Salt Lake City, UT · NPI 1972248557
  NPD Authorized official DENTAL ANESTHESIOLOGY
• Summit Anesthesia, PLLC Dental Anesthesiology · Holladay, UT · NPI 1427840297
  NPD Authorized official DENTAL ANESTHESIOLOGY
• Family Surgical Suite Ambulatory Surgical Clinic/Center · Murray, UT · NPI 1083861165
  NPD
• Family Surgical Suite Anesthesiology Physician · Murray, UT · NPI 1811146384
  NPD

Medicare participation

Medicare fee-for-service enrollment

Enrolled in UT

Eligible to order & refer

Part B services: Yes · DME: Yes · Home health: Yes · Power mobility devices: Yes · Hospice: Yes

Medicare enrollment records

National Provider Directory

Medicare enrollment (NPD)

Yes

State licenses

Practice roles

Locations

Specialties & licenses

Addresses

The complete NPPES record for this NPI in the NPI Registry API JSON format, last updated by the provider on May 19, 2025.

{
    "created_epoch": "1337817600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1747612800000",
    "number": "1649530601",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "5136 S COTTONWOOD LN",
            "city": "HOLLADAY",
            "state": "UT",
            "postal_code": "841177102",
            "telephone_number": "801-718-6395"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "STONY BROOK UNIVERSITY HOSPITAL DEPT OF",
            "city": "STONY BROOK",
            "state": "NY",
            "postal_code": "117948711",
            "telephone_number": "631-444-2557",
            "fax_number": "631-444-6013"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "5136 S Cottonwood Ln",
            "address_purpose": "LOCATION",
            "city": "Holladay",
            "state": "UT",
            "postal_code": "841177102",
            "country_code": "US",
            "telephone_number": "801-718-6395",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "DUCKWORTH",
        "first_name": "MITCHELL",
        "middle_name": "DOUGLAS",
        "name_prefix": "Dr.",
        "credential": "DDS",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2012-05-24",
        "last_updated": "2025-05-19",
        "certification_date": "2025-05-19",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1223D0004X",
            "taxonomy_group": "",
            "desc": "Dentist, Dental Anesthesiology",
            "state": "UT",
            "license": "8926334-9924",
            "primary": false
        },
        {
            "code": "390200000X",
            "taxonomy_group": "",
            "desc": "Student in an Organized Health Care Education/Training Program",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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All providers in Stony Brook, NY · Student in an Organized Health Care Education/Training Program in New York