Provider Demographics
NPI:1689618571
Name:DECKARD, JACK HUDSON (MD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:HUDSON
Last Name:DECKARD
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:5150 N PORT WASHINGTON RD
Mailing Address - Street 2:STE 220
Mailing Address - City:GLENDALE
Mailing Address - State:WI
Mailing Address - Zip Code:53217-5474
Mailing Address - Country:US
Mailing Address - Phone:414-961-0089
Mailing Address - Fax:414-961-1043
Practice Address - Street 1:5150 N PORT WASHINGTON RD
Practice Address - Street 2:STE 220
Practice Address - City:GLENDALE
Practice Address - State:WI
Practice Address - Zip Code:53217-5474
Practice Address - Country:US
Practice Address - Phone:414-961-0089
Practice Address - Fax:414-961-1043
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-15
Last Update Date:2010-08-31
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
WI24495207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30464900Medicaid
WI30464900Medicaid
WI000001544Medicare ID - Type Unspecified