Basic Information
| Provider Information | |||||||||
| NPI: | 1235244484 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DECKER | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | HENRY | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 215 NORTH 35TH STREET | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 53208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4149317600 | ||||||||
| FaxNumber: | 4142719951 | ||||||||
| Practice Location | |||||||||
| Address1: | 215 NORTH 35TH STREET | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532084106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4149317600 | ||||||||
| FaxNumber: | 4142719951 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/20/2006 | ||||||||
| LastUpdateDate: | 12/06/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 26951 | WI | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 2083P0500X | 26951-020 | WI | Y | Allopathic & Osteopathic Physicians | Preventive Medicine | Preventive Medicine/Occupational Environmental Medicine |
ID Information
| ID | Type | State | Issuer | Description | AD3290967 | 01 | DEA NUMBER | OTHER | 31508000 | 05 | WI | MEDICAID |