Provider Demographics
NPI:1447370739
Name:GARY G DECKELBOIM MD PA
Entity type:Organization
Organization Name:GARY G DECKELBOIM MD PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER OPTHALMOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:G
Authorized Official - Last Name:DECKELBOIM
Authorized Official - Suffix:
Authorized Official - Credentials:MD PA
Authorized Official - Phone:903-758-3800
Mailing Address - Street 1:330 E LOOP 281
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75605-7912
Mailing Address - Country:US
Mailing Address - Phone:903-758-7385
Mailing Address - Fax:903-758-3800
Practice Address - Street 1:330 E LOOP 281
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75605-7912
Practice Address - Country:US
Practice Address - Phone:903-758-7385
Practice Address - Fax:903-758-3800
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-30
Last Update Date:2008-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ0940332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1243970001Medicare ID - Type Unspecified
A61669Medicare UPIN