Provider Demographics
NPI:1235244484
Name:DECKER, MARK HENRY (MD)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:HENRY
Last Name:DECKER
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 1:215 NORTH 35TH STREET
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53208
Mailing Address - Country:US
Mailing Address - Phone:414-931-7600
Mailing Address - Fax:414-271-9951
Practice Address - Street 1:215 NORTH 35TH STREET
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53208-4106
Practice Address - Country:US
Practice Address - Phone:414-931-7600
Practice Address - Fax:414-271-9951
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI26951207V00000X
WI26951-0202083P0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083P0500XAllopathic & Osteopathic PhysiciansPreventive MedicinePreventive Medicine/Occupational Environmental Medicine
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI31508000Medicaid
WI31508000Medicaid
AD3290967OtherDEA NUMBER
670050057 HARTFORDMedicare ID - Type UnspecifiedMEDICARE PROVIDER