MEDICARE: DR. MIRANDA DECKER MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	28146	AL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	510-06343	OTHER	AL	BCBS
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1699967612
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MIRANDA DECKER MD

Provider Business Mailing Address
First Line	:	PO BOX 516
Second Line	:	535 GANDY ST
City	:	RUSSELLVILLE
State	:	AL
Zip	:	35653-0516
Country	:	US
Telephone Number	:	256-332-1120
Fax Number	:	256-332-1198

Provider Business Practice Location Address
First Line	:	535 GANDY ST NE
Second Line	:
City	:	RUSSELLVILLE
State	:	AL
Zip	:	35653-1965
Country	:	US
Telephone Number	:	256-332-1120
Fax Number	:	256-332-1198

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/14/2007
Last Update Date	:	10/25/2024

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