Provider Demographics
NPI:1629003462
Name:DECARLO, LOREN J (DO)
Entity type:Individual
Prefix:DR
First Name:LOREN
Middle Name:J
Last Name:DECARLO
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CAPAC
Mailing Address - State:MI
Mailing Address - Zip Code:48014-3715
Mailing Address - Country:US
Mailing Address - Phone:810-395-4840
Mailing Address - Fax:810-395-7551
Practice Address - Street 1:117 S MAIN ST
Practice Address - Street 2:
Practice Address - City:CAPAC
Practice Address - State:MI
Practice Address - Zip Code:48014-3715
Practice Address - Country:US
Practice Address - Phone:810-395-4840
Practice Address - Fax:810-395-7551
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2011-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101013942207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4735675Medicaid
MIH48145Medicare UPIN
MI0P14820 001Medicare ID - Type Unspecified