Provider Demographics
NPI:1376626127
Name:DECOSSARD, PANY (MD)
Entity Type:Individual
Prefix:
First Name:PANY
Middle Name:
Last Name:DECOSSARD
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:PO BOX 126
Mailing Address - Street 2:
Mailing Address - City:DECKERVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48427-0126
Mailing Address - Country:US
Mailing Address - Phone:810-376-2835
Mailing Address - Fax:810-376-9713
Practice Address - Street 1:3559 PINE STREET
Practice Address - Street 2:
Practice Address - City:DECKERVILLE
Practice Address - State:MI
Practice Address - Zip Code:48427-0126
Practice Address - Country:US
Practice Address - Phone:810-376-2835
Practice Address - Fax:810-376-9713
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301083294207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4694760Medicaid
MI4694760Medicaid
MIM32640013Medicare ID - Type Unspecified