Provider Demographics
NPI:1639341365
Name:DECKER, JOSHUA ROBERT (DPM)
Entity Type:Individual
Prefix:DR
First Name:JOSHUA
Middle Name:ROBERT
Last Name:DECKER
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4540 KALAMAZOO AVE SE
Mailing Address - Street 2:
Mailing Address - City:KENTWOOD
Mailing Address - State:MI
Mailing Address - Zip Code:49508-4625
Mailing Address - Country:US
Mailing Address - Phone:616-281-0666
Mailing Address - Fax:616-281-0752
Practice Address - Street 1:1195 WILSON AVE NW
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49534-3493
Practice Address - Country:US
Practice Address - Phone:616-453-8277
Practice Address - Fax:616-453-2002
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-02
Last Update Date:2009-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5901002241213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI480026386OtherRAILROAD MEDICARE
MI1639341365OtherRAILROAD MEDICARE
MIOM71140OtherMEDICARE ID - TYPE UNSPECIFIED
MI1266510001OtherADMINISTAR
MI5494683Medicaid