Active NPI
Jack Hudson Deckard, MD
- Neurological Surgery Physician
- Glendale, WI
National Provider Identifier
1689618571
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Neurological Surgery Physician
- License
- 24495
- Practice address
- 5150 N Port Washington Rd
Ste 220
Glendale, WI 53217-5474 - Phone
- (414) 961-0089
- Fax
- (414) 961-1043
- NPI assigned
- Jun 15, 2006
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Neurological Surgery Physician | 207T00000X | 24495 | WI | Primary |
Addresses
Primary practice location
5150 N Port Washington Rd
Ste 220
Glendale, WI 53217-5474
Mailing address
5150 N Port Washington Rd
Ste 220
Glendale, WI 53217-5474
Phone (414) 961-0089
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 30464900 | Medicaid | WI |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Doctor of Medicine
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 24495 | WI | MD | Neurological Surgery Physician |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1150329600000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1283212800000",
"number": "1689618571",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "5150 N PORT WASHINGTON RD",
"address_2": "STE 220",
"city": "GLENDALE",
"state": "WI",
"postal_code": "532175474",
"telephone_number": "414-961-0089",
"fax_number": "414-961-1043"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "5150 N PORT WASHINGTON RD",
"address_2": "STE 220",
"city": "GLENDALE",
"state": "WI",
"postal_code": "532175474",
"telephone_number": "414-961-0089",
"fax_number": "414-961-1043"
}
],
"practiceLocations": [],
"basic": {
"last_name": "DECKARD",
"first_name": "JACK",
"middle_name": "HUDSON",
"name_prefix": "Dr.",
"credential": "MD",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2006-06-15",
"last_updated": "2010-08-31",
"status": "A"
},
"taxonomies": [
{
"code": "207T00000X",
"taxonomy_group": "",
"desc": "Neurological Surgery",
"state": "WI",
"license": "24495",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "30464900",
"state": "WI"
}
],
"endpoints": [],
"other_names": []
}Other providers in Glendale, WI
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 31, 2010; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.