Basic Information
| Provider Information | |||||||||
| NPI: | 1689764151 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DENEKE | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4301 W MARKHAM ST # 783 | ||||||||
| Address2: | |||||||||
| City: | LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 722057199 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5016868000 | ||||||||
| FaxNumber: | 5015264596 | ||||||||
| Practice Location | |||||||||
| Address1: | 4301 W MARKHAM ST # 783 | ||||||||
| Address2: | |||||||||
| City: | LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 72205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5016868000 | ||||||||
| FaxNumber: | 5015264596 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/13/2006 | ||||||||
| LastUpdateDate: | 09/26/2018 | ||||||||
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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 | 207RG0100X | 107008 | MN | N | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | 207RG0100X | 56852 | MN | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | 207R00000X | E-4436 | AR | N | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 157947001 | 05 | AR | MEDICAID | 05060013900 | 01 | AR | QUALCHOICE | OTHER | 5N259 | 01 | AR | BCBS | OTHER | P00295353 | 01 | AR | RAILROAD MEDICARE1 | OTHER |