Provider Demographics
NPI:1437883709
Name:DECKER, THOMAS JAY I
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:JAY
Last Name:DECKER
Suffix:I
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 MONTCALM ST
Mailing Address - Street 2:
Mailing Address - City:TICONDEROGA
Mailing Address - State:NY
Mailing Address - Zip Code:12883-1393
Mailing Address - Country:US
Mailing Address - Phone:518-585-7934
Mailing Address - Fax:518-585-9132
Practice Address - Street 1:50 MONTCALM ST
Practice Address - Street 2:
Practice Address - City:TICONDEROGA
Practice Address - State:NY
Practice Address - Zip Code:12883-1393
Practice Address - Country:US
Practice Address - Phone:518-585-7934
Practice Address - Fax:518-585-9132
Is Sole Proprietor?:No
Enumeration Date:2022-07-13
Last Update Date:2022-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1629172762Medicaid