Provider Demographics
NPI:1942279914
Name:DECAYETTE, JACQUELINE I (MD)
Entity Type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:I
Last Name:DECAYETTE
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 1:210 N TUSTIN AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92705-3807
Mailing Address - Country:US
Mailing Address - Phone:714-347-1010
Mailing Address - Fax:714-647-1245
Practice Address - Street 1:1300 MABLE AVE # 1
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95355-1120
Practice Address - Country:US
Practice Address - Phone:209-571-1633
Practice Address - Fax:209-491-0772
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-14
Last Update Date:2015-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA43343207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A433430Medicaid
CA050090117Medicare PIN
CA00A433430Medicaid
CA00A433430Medicare PIN
CAF17584Medicare UPIN