Provider Demographics
NPI:1043274129
Name:DECKER, GARY LEE (MD)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:LEE
Last Name:DECKER
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 1:1301 NE 1ST ST
Mailing Address - Street 2:
Mailing Address - City:PRYOR
Mailing Address - State:OK
Mailing Address - Zip Code:74361-8850
Mailing Address - Country:US
Mailing Address - Phone:918-824-7767
Mailing Address - Fax:918-824-6410
Practice Address - Street 1:1301 NE 1ST ST
Practice Address - Street 2:
Practice Address - City:PRYOR
Practice Address - State:OK
Practice Address - Zip Code:74361-8850
Practice Address - Country:US
Practice Address - Phone:918-824-7767
Practice Address - Fax:918-824-6410
Is Sole Proprietor?:No
Enumeration Date:2006-04-14
Last Update Date:2011-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK14290208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100194650AMedicaid
OK200039950AMedicaid
OK200039950AMedicaid
OK500522114Medicare PIN