Provider Demographics
NPI:1447255229
Name:DECAPRIO, JEFFREY DAVID (MD)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:DAVID
Last Name:DECAPRIO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5002 COWHORN CREEK RD
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75503-9766
Mailing Address - Country:US
Mailing Address - Phone:903-614-3000
Mailing Address - Fax:903-614-3525
Practice Address - Street 1:5002 COWHORN CREEK RD
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75503-9766
Practice Address - Country:US
Practice Address - Phone:903-614-3000
Practice Address - Fax:903-614-3525
Is Sole Proprietor?:No
Enumeration Date:2005-06-17
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK02842086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX03080021800OtherQUALCHOICE QCA OF AR
TX157600102Medicaid
TX0035MHOtherBLUE CROSS/BLUE SHIELD
TX157600103Medicaid
AR149598001Medicaid
AR82411OtherGROUP 8-P149
TX157600103Medicaid
AR82411OtherGROUP 8-P149