Provider Demographics
NPI:1871600676
Name:DECKER, TODD EDWARD (MD)
Entity type:Individual
Prefix:
First Name:TODD
Middle Name:EDWARD
Last Name:DECKER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:2325 SUMMIT PARK DR
Mailing Address - Street 2:SUITE 3
Mailing Address - City:PETOSKEY
Mailing Address - State:MI
Mailing Address - Zip Code:49770-8774
Mailing Address - Country:US
Mailing Address - Phone:231-439-5100
Mailing Address - Fax:231-439-9292
Practice Address - Street 1:2325 SUMMIT PARK DR
Practice Address - Street 2:SUITE 3
Practice Address - City:PETOSKEY
Practice Address - State:MI
Practice Address - Zip Code:49770-8774
Practice Address - Country:US
Practice Address - Phone:231-439-5100
Practice Address - Fax:231-439-9292
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-25
Last Update Date:2021-03-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MI4301079910207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4831976Medicaid
MI0B41093OtherBCBS
MIH28582Medicare UPIN
MI4831976Medicaid