Provider Demographics
NPI:1841238490
Name:DECELLES, JOHN M (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:M
Last Name:DECELLES
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 6309
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46660-6309
Mailing Address - Country:US
Mailing Address - Phone:574-472-6700
Mailing Address - Fax:574-472-6746
Practice Address - Street 1:611 E DOUGLAS RD
Practice Address - Street 2:SUITE 309
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46545-1467
Practice Address - Country:US
Practice Address - Phone:574-472-6450
Practice Address - Fax:574-472-6474
Is Sole Proprietor?:No
Enumeration Date:2006-06-04
Last Update Date:2009-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01051161207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000215219OtherBCBS
IN200228210AMedicaid
IN021236800OtherFEDERAL BLACK LUNG
IN000000215219OtherBCBS
IN200228210AMedicaid
IN110229017Medicare PIN