Provider Demographics
NPI:1669441960
Name:DECKER, CLARICE R (MD)
Entity Type:Individual
Prefix:
First Name:CLARICE
Middle Name:R
Last Name:DECKER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11475 ROBINSON DR NW
Mailing Address - Street 2:
Mailing Address - City:COON RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55433-3746
Mailing Address - Country:US
Mailing Address - Phone:763-587-9000
Mailing Address - Fax:763-587-9130
Practice Address - Street 1:11475 ROBINSON DR NW
Practice Address - Street 2:
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55433-3746
Practice Address - Country:US
Practice Address - Phone:763-587-9000
Practice Address - Fax:763-587-9130
Is Sole Proprietor?:No
Enumeration Date:2006-03-17
Last Update Date:2013-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN37105207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN719025500Medicaid
160002380Medicare ID - Type Unspecified
MN719025500Medicaid