Provider Demographics
NPI:1366597866
Name:JOSEPH F DECKER PROFESSIONAL CORP
Entity type:Organization
Organization Name:JOSEPH F DECKER PROFESSIONAL CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:F
Authorized Official - Last Name:DECKER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:435-753-3277
Mailing Address - Street 1:1365 SUMAC DR
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84321-4819
Mailing Address - Country:US
Mailing Address - Phone:435-753-3277
Mailing Address - Fax:
Practice Address - Street 1:164 S 5TH
Practice Address - Street 2:
Practice Address - City:MONTPELIER
Practice Address - State:ID
Practice Address - Zip Code:83254
Practice Address - Country:US
Practice Address - Phone:435-753-3277
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM3611208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID80515OtherBLUE CROSS
000010001738OtherBLUE SHIELD
ID80515OtherBLUE CROSS
D20418Medicare UPIN