Provider Demographics
NPI:1245257914
Name:DECENA, CLSUDIO REBOSURA
Entity type:Individual
Prefix:
First Name:CLSUDIO
Middle Name:REBOSURA
Last Name:DECENA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4101 S 4TH ST
Mailing Address - Street 2:
Mailing Address - City:LEAVENWORTH
Mailing Address - State:KS
Mailing Address - Zip Code:66048-5014
Mailing Address - Country:US
Mailing Address - Phone:913-682-2000
Mailing Address - Fax:
Practice Address - Street 1:117 ROCK CREEK LOOP
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:KS
Practice Address - Zip Code:66043-6211
Practice Address - Country:US
Practice Address - Phone:913-250-0468
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS0418828208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery