1275651952 NPI number — DR. MARYANN KATHLEEN DECKER OPTOMETRIST

Table of content: DR. MARYANN KATHLEEN DECKER OPTOMETRIST (NPI 1275651952)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275651952 NPI number — DR. MARYANN KATHLEEN DECKER OPTOMETRIST

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DECKER
Provider First Name:
MARYANN
Provider Middle Name:
KATHLEEN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
OPTOMETRIST
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1275651952
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
522 ROCKY GLEN RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
AVOCA
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
18641-9508
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
570-457-0437
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
PEARLE VISION 820 SCRANTON CARBONDALE HIGHWAY
Provider Second Line Business Practice Location Address:
EYNON PLAZA
Provider Business Practice Location Address City Name:
EYNON
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18403
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-876-5050
Provider Business Practice Location Address Fax Number:
570-876-3526
Provider Enumeration Date:
03/27/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  OEG001325 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 152WC0802X , with the licence number: OEG001325 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

Other Provider's Identifiers (legacy, non-NPI)





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