Provider Demographics
NPI:1376519645
Name:DECOSMO, MICHAEL J (DO)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:J
Last Name:DECOSMO
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Mailing Address - Street 1:1 GREENVALE RD
Mailing Address - Street 2:
Mailing Address - City:CHERRY HILL
Mailing Address - State:NJ
Mailing Address - Zip Code:08034-1703
Mailing Address - Country:US
Mailing Address - Phone:856-667-8059
Mailing Address - Fax:
Practice Address - Street 1:2201 CHAPEL AVE W
Practice Address - Street 2:SUITE 102
Practice Address - City:CHERRY HILL
Practice Address - State:NJ
Practice Address - Zip Code:08002-2048
Practice Address - Country:US
Practice Address - Phone:856-662-7883
Practice Address - Fax:856-662-5838
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-27
Last Update Date:2010-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMBO25986207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ3901408Medicaid
NJC54230Medicare UPIN
NJ3901408Medicaid