Provider Demographics
NPI:1023002862
Name:DECKER, MARK J (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:J
Last Name:DECKER
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:150 E SUNRISE HWY
Mailing Address - Street 2:208
Mailing Address - City:LINDENHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11757-2598
Mailing Address - Country:US
Mailing Address - Phone:631-225-7200
Mailing Address - Fax:631-930-9451
Practice Address - Street 1:150 E SUNRISE HWY
Practice Address - Street 2:208
Practice Address - City:LINDENHURST
Practice Address - State:NY
Practice Address - Zip Code:11757-2598
Practice Address - Country:US
Practice Address - Phone:631-225-7200
Practice Address - Fax:631-930-9451
Is Sole Proprietor?:No
Enumeration Date:2005-09-08
Last Update Date:2011-04-04
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Provider Licenses
StateLicense IDTaxonomies
NY2069442085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TRICARE NORTHOther059587550
NY0521AAOtherGHI MEDICARE
NY01856591Medicaid
NY01856591Medicaid
NY613961Medicare PIN