Provider Demographics
NPI:1851360036
Name:DECOTIIS, MARK ANTHONY (DPM)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ANTHONY
Last Name:DECOTIIS
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:721 N BEERS ST
Mailing Address - Street 2:STE. 2C
Mailing Address - City:HOLMDEL
Mailing Address - State:NJ
Mailing Address - Zip Code:07733-1518
Mailing Address - Country:US
Mailing Address - Phone:732-888-1717
Mailing Address - Fax:732-888-2101
Practice Address - Street 1:721 N BEERS ST
Practice Address - Street 2:STE. 2C
Practice Address - City:HOLMDEL
Practice Address - State:NJ
Practice Address - Zip Code:07733-1518
Practice Address - Country:US
Practice Address - Phone:732-888-1717
Practice Address - Fax:732-888-2101
Is Sole Proprietor?:No
Enumeration Date:2006-03-17
Last Update Date:2014-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMD02381213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
10654598OtherCAQH
2K6416OtherHEALTH NET
P1093167OtherOXFORD ID
PJ3001OtherEMPIRE BCBS
011631Medicare ID - Type UnspecifiedINDIVIDUAL MEDICARE NUMBE
2K6416OtherHEALTH NET
10654598OtherCAQH