Provider Demographics
NPI:1730100892
Name:DECKELBAUM, SCOTT HOWARD (DO)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:HOWARD
Last Name:DECKELBAUM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:248 PLEASANT ST STE 2800
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NH
Mailing Address - Zip Code:03301-7529
Mailing Address - Country:US
Mailing Address - Phone:603-415-6464
Mailing Address - Fax:603-227-7576
Practice Address - Street 1:248 PLEASANT ST STE 2800
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NH
Practice Address - Zip Code:03301-7529
Practice Address - Country:US
Practice Address - Phone:603-415-6464
Practice Address - Fax:603-227-7576
Is Sole Proprietor?:No
Enumeration Date:2006-07-22
Last Update Date:2023-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5176207N00000X, 207Q00000X
CA20A10789207N00000X, 207Q00000X
NY235559207N00000X
FLOS14334207ND0101X
NY235559-1207Q00000X
NH23933207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02806417Medicaid
NYJ400097112Medicare PIN
NYRB5982Medicare PIN
NYRB1672Medicare PIN
NYL66837Medicare UPIN
NY02806417Medicaid