Provider Demographics
NPI:1790879633
Name:DECLUE, ANN D (MD)
Entity Type:Individual
Prefix:
First Name:ANN
Middle Name:D
Last Name:DECLUE
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 1:990 BELVEDERE DR STE A
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:OH
Mailing Address - Zip Code:45036-2890
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:990 BELVEDERE DR STE A
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:OH
Practice Address - Zip Code:45036-2890
Practice Address - Country:US
Practice Address - Phone:240-313-9850
Practice Address - Fax:240-313-9851
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2013-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36073550207R00000X
OH35.120757207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0086602Medicaid
OH0086602Medicaid