Provider Demographics
NPI:1063404044
Name:DECARLI, JOHN FREDERICK (DO)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:FREDERICK
Last Name:DECARLI
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2405 LANDON DR
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19810-3511
Mailing Address - Country:US
Mailing Address - Phone:302-761-9620
Mailing Address - Fax:
Practice Address - Street 1:700 W LEA BLVD
Practice Address - Street 2:SUITE 306
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19802-2500
Practice Address - Country:US
Practice Address - Phone:302-761-9620
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC2-0002853207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE0000022903Medicaid
DE0000022903Medicaid
DEE21828Medicare UPIN