Provider Demographics
NPI:1790778991
Name:DECOLLI, ROBERT A JR (DO)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:A
Last Name:DECOLLI
Suffix:JR
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 1:2252 LAMAR AVE
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38114-6608
Mailing Address - Country:US
Mailing Address - Phone:901-671-1800
Mailing Address - Fax:901-671-0056
Practice Address - Street 1:2252 LAMAR AVE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38114-6608
Practice Address - Country:US
Practice Address - Phone:901-671-1800
Practice Address - Fax:901-671-0056
Is Sole Proprietor?:No
Enumeration Date:2005-08-24
Last Update Date:2021-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN4200207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0015039900003Medicaid
PA110104720OtherRAILROAD MEDICARE
PA0015039900003Medicaid
PAF97972Medicare UPIN