Provider Demographics
NPI:1881610384
Name:DECKELMAN, MARY C (MD)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:C
Last Name:DECKELMAN
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 1:452 MARYLEBORN RD
Mailing Address - Street 2:
Mailing Address - City:SEVERNA PARK
Mailing Address - State:MD
Mailing Address - Zip Code:21146-1667
Mailing Address - Country:US
Mailing Address - Phone:216-533-1713
Mailing Address - Fax:
Practice Address - Street 1:452 MARYLEBORN RD
Practice Address - Street 2:
Practice Address - City:SEVERNA PARK
Practice Address - State:MD
Practice Address - Zip Code:21146-1667
Practice Address - Country:US
Practice Address - Phone:216-533-1713
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-15
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH350824922084P0804X
MDD406842084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000532995OtherANTHEM
OH2431078Medicaid
OH5140115OtherAETNA
OH000000224470OtherUNISON
OH363471OtherWELLCARE MEDICAID
F99160Medicare UPIN
OH5140115OtherAETNA
OHDE4116551Medicare PIN