Provider Demographics
NPI:1396727095
Name:DECKER, GUSTAV A (MD)
Entity type:Individual
Prefix:DR
First Name:GUSTAV
Middle Name:A
Last Name:DECKER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 1ST ST SW
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55905-0001
Mailing Address - Country:US
Mailing Address - Phone:507-284-2511
Mailing Address - Fax:
Practice Address - Street 1:6350 E GALBRAITH RD
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45236-2276
Practice Address - Country:US
Practice Address - Phone:513-686-6860
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-17
Last Update Date:2024-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ32905207RG0100X
OH35130129207RG0100X
MN40257207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZP00172759OtherRAILROAD MEDICARE
AZ86080015085259A953OtherTRIWEST
AZ868044Medicaid
H13714Medicare UPIN
AZ86080015085259A953OtherTRIWEST
AZP00172759OtherRAILROAD MEDICARE