Provider Demographics
NPI:1508050311
Name:DECKINGA, BRUCE G (MD)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:G
Last Name:DECKINGA
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 1:8872 DEER RUN
Mailing Address - Street 2:
Mailing Address - City:PETOSKEY
Mailing Address - State:MI
Mailing Address - Zip Code:49770-8593
Mailing Address - Country:US
Mailing Address - Phone:231-347-7681
Mailing Address - Fax:
Practice Address - Street 1:8872 DEER RUN
Practice Address - Street 2:
Practice Address - City:PETOSKEY
Practice Address - State:MI
Practice Address - Zip Code:49770-8593
Practice Address - Country:US
Practice Address - Phone:231-347-7681
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-05
Last Update Date:2008-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIMI43030312208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIB43890Medicare UPIN