Provider Demographics
NPI:1578512257
Name:DECKER, JOHN THADDEUS (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:THADDEUS
Last Name:DECKER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:J
Other - Middle Name:THAD
Other - Last Name:DECKER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:2424 N WYATT DR STE 260
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85712-6118
Mailing Address - Country:US
Mailing Address - Phone:520-795-8080
Mailing Address - Fax:520-323-6237
Practice Address - Street 1:6452 E CARONDELET DR STE 100
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85710-2262
Practice Address - Country:US
Practice Address - Phone:520-323-0333
Practice Address - Fax:520-323-5036
Is Sole Proprietor?:No
Enumeration Date:2006-05-09
Last Update Date:2024-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ25939207V00000X, 207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ499253Medicaid
AZZ117553Medicare PIN