Provider Demographics
NPI:1912083106
Name:DECCO, MARK L (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:L
Last Name:DECCO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:17965 HALL RD
Mailing Address - Street 2:
Mailing Address - City:MACOMB
Mailing Address - State:MI
Mailing Address - Zip Code:48044-4557
Mailing Address - Country:US
Mailing Address - Phone:586-846-3073
Mailing Address - Fax:586-846-3074
Practice Address - Street 1:21300 KELLY RD
Practice Address - Street 2:
Practice Address - City:EASTPOINTE
Practice Address - State:MI
Practice Address - Zip Code:48021
Practice Address - Country:US
Practice Address - Phone:586-447-4200
Practice Address - Fax:586-447-4208
Is Sole Proprietor?:No
Enumeration Date:2006-10-31
Last Update Date:2018-04-17
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MI4301073354207K00000X, 2080P0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
No2080P0201XAllopathic & Osteopathic PhysiciansPediatricsPediatric Allergy/Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
G18962Medicare UPIN