Provider Demographics
NPI:1225331481
Name:DECKELBAUM, DAN (MD)
Entity Type:Individual
Prefix:DR
First Name:DAN
Middle Name:
Last Name:DECKELBAUM
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 1:305 RUE DE LA COMMUNE, #11
Mailing Address - Street 2:
Mailing Address - City:MONTREAL
Mailing Address - State:QUEBEC
Mailing Address - Zip Code:H2Y2E1
Mailing Address - Country:CA
Mailing Address - Phone:514-550-2548
Mailing Address - Fax:
Practice Address - Street 1:1650 CEDAR AVE, , L9.411
Practice Address - Street 2:
Practice Address - City:MONTREAL
Practice Address - State:QUEBEC
Practice Address - Zip Code:H3G1A4
Practice Address - Country:CA
Practice Address - Phone:514-934-1934
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-09
Last Update Date:2010-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ZZ0144432086S0127X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma Surgery