Provider Demographics
NPI:1356624183
Name:GARY G. DECKELBOIM, M.D. P.A.
Entity type:Organization
Organization Name:GARY G. DECKELBOIM, M.D. P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:G
Authorized Official - Last Name:DECKELBOIM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:214-369-8478
Mailing Address - Street 1:8210 WALNUT HILL LANE
Mailing Address - Street 2:SUITE 100 LB-5
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75231-4418
Mailing Address - Country:US
Mailing Address - Phone:214-369-8478
Mailing Address - Fax:214-696-1594
Practice Address - Street 1:8210 WALNUT HILL LANE
Practice Address - Street 2:SUITE 100 LB-5
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75231-4418
Practice Address - Country:US
Practice Address - Phone:214-369-8478
Practice Address - Fax:214-696-1594
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-28
Last Update Date:2011-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ0940207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty