Provider Demographics
NPI:1306827514
Name:DECLUE, JEYCE (DPM)
Entity Type:Individual
Prefix:
First Name:JEYCE
Middle Name:
Last Name:DECLUE
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 BIRCH HILL RD
Mailing Address - Street 2:
Mailing Address - City:MOUNT SINAI
Mailing Address - State:NY
Mailing Address - Zip Code:11766-1903
Mailing Address - Country:US
Mailing Address - Phone:631-338-4329
Mailing Address - Fax:
Practice Address - Street 1:3049 BRIGHTON 6TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11235-6409
Practice Address - Country:US
Practice Address - Phone:718-872-5721
Practice Address - Fax:718-872-5722
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-07
Last Update Date:2012-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN006064213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02953419Medicaid
NY02953419Medicaid
NYV03746Medicare UPIN