Provider Demographics
NPI:1356336846
Name:DECKER, GARY ALFRED (M D)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:ALFRED
Last Name:DECKER
Suffix:
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 61148
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32236-1148
Mailing Address - Country:US
Mailing Address - Phone:904-308-3696
Mailing Address - Fax:904-308-3697
Practice Address - Street 1:3627 UNIVERSITY BLVD S
Practice Address - Street 2:SUITE 415
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-4230
Practice Address - Country:US
Practice Address - Phone:904-398-5123
Practice Address - Fax:904-398-9157
Is Sole Proprietor?:No
Enumeration Date:2005-09-12
Last Update Date:2019-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0034917207RA0401X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL039554400Medicaid
FL15561Medicare ID - Type Unspecified
FL039554400Medicaid