Provider Demographics
NPI:1235283425
Name:JEFFREY D DECAPRIO MD PA
Entity Type:Organization
Organization Name:JEFFREY D DECAPRIO MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:D DECAPRIO
Authorized Official - Last Name:MD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:903-255-0002
Mailing Address - Street 1:PO BOX 6124
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75505-6124
Mailing Address - Country:US
Mailing Address - Phone:903-255-0002
Mailing Address - Fax:
Practice Address - Street 1:2717 SUMMERHILL RD
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75503-3957
Practice Address - Country:US
Practice Address - Phone:903-794-0022
Practice Address - Fax:903-794-0023
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-23
Last Update Date:2008-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK02842086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR8P149OtherBC AR
TX0035MHOtherBC TX
TX030800221800OtherQUALCHOICE
AR15668002Medicaid
TXDD1753OtherRR MEDICARE
TX0035MHOtherBC TX
AR15668002Medicaid