Healthcare Provider Details

I. General information

NPI: 1386922151
Provider Name (Legal Business Name): DPMDECKERPRCT, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/28/2011
Last Update Date: 07/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 HEBRON AVE SUITE 211
GLASTONBURY CT
06033-2176
US

IV. Provider business mailing address

196 PARKWAY S SUITE 304
WATERFORD CT
06385-1234
US

V. Phone/Fax

Practice location:
  • Phone: 860-657-3668
  • Fax: 860-657-1678
Mailing address:
  • Phone: 860-442-7027
  • Fax: 860-437-2236

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number000853
License Number StateCT

VIII. Authorized Official

Name: JENNIFER R DECKER
Title or Position: OWNER/PODIATRIST
Credential: DPM
Phone: 860-657-3668