Provider Demographics
NPI:1750342515
Name:DECANIO, ROGELIO R (MD)
Entity type:Individual
Prefix:
First Name:ROGELIO
Middle Name:R
Last Name:DECANIO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5620 SOUTHWYCK BLVD
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43614-1501
Mailing Address - Country:US
Mailing Address - Phone:800-777-2931
Mailing Address - Fax:
Practice Address - Street 1:1001 BELLEFONTAINE AVE
Practice Address - Street 2:
Practice Address - City:LIMA
Practice Address - State:OH
Practice Address - Zip Code:45804-2800
Practice Address - Country:US
Practice Address - Phone:419-226-5058
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2007-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35064350174400000X
OH35064350D207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0759481Medicare ID - Type Unspecified
OHE77943Medicare UPIN