Provider Demographics
NPI:1235104886
Name:DECLUE, JOHN A (DO)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:A
Last Name:DECLUE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 CARSON CT
Mailing Address - Street 2:
Mailing Address - City:BAINBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:39819-2700
Mailing Address - Country:US
Mailing Address - Phone:706-464-2539
Mailing Address - Fax:
Practice Address - Street 1:2181 ORANGE AVE E
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32311-6144
Practice Address - Country:US
Practice Address - Phone:850-878-0191
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-17
Last Update Date:2024-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA037522207Q00000X
MO2014010401207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1235104886Medicaid
MO124920003OtherMEDICARE PTAN
GA00571326FMedicaid
GA480095OtherBLUECROSSBLUESHIELD
GA480095OtherBLUECROSSBLUESHIELD
F69095Medicare UPIN
080190206Medicare ID - Type UnspecifiedRAIL ROAD