Provider Demographics
NPI:1235104886
Name:DECLUE, JOHN A (DO)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:A
Last Name:DECLUE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3536 KUHNE RD
Mailing Address - Street 2:
Mailing Address - City:OWENSVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:65066-2573
Mailing Address - Country:US
Mailing Address - Phone:573-437-4168
Mailing Address - Fax:573-437-4242
Practice Address - Street 1:3536 KUHNE RD
Practice Address - Street 2:
Practice Address - City:OWENSVILLE
Practice Address - State:MO
Practice Address - Zip Code:65066-2573
Practice Address - Country:US
Practice Address - Phone:573-437-4168
Practice Address - Fax:573-437-4242
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-17
Last Update Date:2014-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2014010401207Q00000X
GA037522207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA480095OtherBLUECROSSBLUESHIELD
MO1235104886Medicaid
MO124920003OtherMEDICARE PTAN
GA00571326FMedicaid
GA480095OtherBLUECROSSBLUESHIELD
F69095Medicare UPIN
080190206Medicare ID - Type UnspecifiedRAIL ROAD