Provider Demographics
NPI:1992814842
Name:DECANDIA, MICHAEL (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:DECANDIA
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 1:2121 E GRIFFIN PKWY
Mailing Address - Street 2:SUITE 12
Mailing Address - City:MISSION
Mailing Address - State:TX
Mailing Address - Zip Code:78572-3241
Mailing Address - Country:US
Mailing Address - Phone:956-581-0303
Mailing Address - Fax:
Practice Address - Street 1:1401 E 8TH ST
Practice Address - Street 2:
Practice Address - City:WESLACO
Practice Address - State:TX
Practice Address - Zip Code:78596-6640
Practice Address - Country:US
Practice Address - Phone:956-581-0303
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2007-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK31522085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXDC0004OtherMEDICARE RAILROAD GRP
TXP00141786OtherMEDICARE RAILROAD INDV
TXDC0004OtherMEDICARE RAILROAD GRP
TX8222N0Medicare PIN
TXP00141786OtherMEDICARE RAILROAD INDV