Provider Demographics
NPI:1578512257
Name:DECKER, JOHN THADDEUS (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:THADDEUS
Last Name:DECKER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:J
Other - Middle Name:THAD
Other - Last Name:DECKER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:3938 EAST GRANT ROAD
Mailing Address - Street 2:STE 248
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85712-2559
Mailing Address - Country:US
Mailing Address - Phone:520-298-3006
Mailing Address - Fax:520-296-4132
Practice Address - Street 1:6567 EAST CARONDELET
Practice Address - Street 2:STE 455
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85710-6155
Practice Address - Country:US
Practice Address - Phone:520-866-6486
Practice Address - Fax:520-296-4132
Is Sole Proprietor?:No
Enumeration Date:2006-05-09
Last Update Date:2019-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ25931207V00000X
AZ25939207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ499253Medicaid
AZZ117553Medicare PIN