Healthcare Provider Details

I. General information

NPI: 1669766861
Provider Name (Legal Business Name): SAMAR DEKKO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2011
Last Update Date: 05/22/2020
Certification Date: 05/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 PROSPECT AVE
HACKENSACK NJ
07601-1915
US

IV. Provider business mailing address

190 ASPEN DR
CEDAR GROVE NJ
07009-2301
US

V. Phone/Fax

Practice location:
  • Phone: 551-996-4466
  • Fax:
Mailing address:
  • Phone: 678-276-9400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number25MA08939000
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: