Healthcare Provider Details

I. General information

NPI: 1639341365
Provider Name (Legal Business Name): JOSHUA ROBERT DECKER DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/02/2008
Last Update Date: 09/29/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1195 WILSON AVE NW
GRAND RAPIDS MI
49534-3493
US

IV. Provider business mailing address

4540 KALAMAZOO AVE SE
KENTWOOD MI
49508-4625
US

V. Phone/Fax

Practice location:
  • Phone: 616-453-8277
  • Fax: 616-453-2002
Mailing address:
  • Phone: 616-281-0666
  • Fax: 616-281-0752

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number5901002241
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: