Provider Demographics
NPI:1386922151
Name:DPMDECKERPRCT, LLC
Entity type:Organization
Organization Name:DPMDECKERPRCT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PODIATRIST
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:R
Authorized Official - Last Name:DECKER
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:860-657-3668
Mailing Address - Street 1:196 PARKWAY S
Mailing Address - Street 2:SUITE 304
Mailing Address - City:WATERFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06385-1234
Mailing Address - Country:US
Mailing Address - Phone:860-442-7027
Mailing Address - Fax:860-437-2236
Practice Address - Street 1:300 HEBRON AVE
Practice Address - Street 2:SUITE 211
Practice Address - City:GLASTONBURY
Practice Address - State:CT
Practice Address - Zip Code:06033-2176
Practice Address - Country:US
Practice Address - Phone:860-657-3668
Practice Address - Fax:860-657-1678
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-28
Last Update Date:2011-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000853332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTD100047985Medicare PIN