Basic Information
| Provider Information | |||||||||
| NPI: | 1033561725 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MICHAEL DECKER, DO, INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 565 PIER AVE | ||||||||
| Address2: | 1352 | ||||||||
| City: | HERMOSA BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902548200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8168961355 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 565 PIER AVE | ||||||||
| Address2: | 1352 | ||||||||
| City: | HERMOSA BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902548200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8168961355 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2016 | ||||||||
| LastUpdateDate: | 07/06/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DECKER | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN/OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7145062450 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | DO | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 20A13087 | CA | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.