Provider Demographics
NPI:1144279209
Name:DECKER, GARY RAYMOND (MD)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:RAYMOND
Last Name:DECKER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:545 N RIVER ST
Mailing Address - Street 2:SUITE 205
Mailing Address - City:WILKES BARRE
Mailing Address - State:PA
Mailing Address - Zip Code:18702-2600
Mailing Address - Country:US
Mailing Address - Phone:570-822-6036
Mailing Address - Fax:570-829-1520
Practice Address - Street 1:545 N RIVER ST
Practice Address - Street 2:SUITE 205
Practice Address - City:WILKES BARRE
Practice Address - State:PA
Practice Address - Zip Code:18702-2600
Practice Address - Country:US
Practice Address - Phone:570-822-6036
Practice Address - Fax:570-829-1520
Is Sole Proprietor?:No
Enumeration Date:2006-05-08
Last Update Date:2010-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD042296E207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0012845610001Medicaid
PA075321OtherFIRST PRIORITY HEALTH
PA8408OtherGEISINGER HEALTH PLAN
PA102861OtherUNISON HEALTH PLAN
PA710341OtherHIGHMARK BLUE SHIELD
PA710341OtherFIRST PRIORITY LIFE
PA075321OtherFIRST PRIORITY HEALTH
PA102861OtherUNISON HEALTH PLAN