Basic Information
| Provider Information | |||||||||
| NPI: | 1992814842 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DECANDIA | ||||||||
| FirstName: | MICHAEL | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2121 E GRIFFIN PKWY | ||||||||
| Address2: | SUITE 12 | ||||||||
| City: | MISSION | ||||||||
| State: | TX | ||||||||
| PostalCode: | 785723241 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9565810303 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1401 E 8TH ST | ||||||||
| Address2: | |||||||||
| City: | WESLACO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 785966640 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9565810303 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2006 | ||||||||
| LastUpdateDate: | 11/02/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | K3152 | TX | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | DC0004 | 01 | TX | MEDICARE RAILROAD GRP | OTHER | P00141786 | 01 | TX | MEDICARE RAILROAD INDV | OTHER |