Provider Demographics
NPI:1154322956
Name:ENNIS-DECKER, TERESA MARIE (OD)
Entity Type:Individual
Prefix:MRS
First Name:TERESA
Middle Name:MARIE
Last Name:ENNIS-DECKER
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9575 STATE RD
Mailing Address - Street 2:
Mailing Address - City:MILLINGTON
Mailing Address - State:MI
Mailing Address - Zip Code:48746-9482
Mailing Address - Country:US
Mailing Address - Phone:989-871-9552
Mailing Address - Fax:989-871-9554
Practice Address - Street 1:9575 STATE RD
Practice Address - Street 2:
Practice Address - City:MILLINGTON
Practice Address - State:MI
Practice Address - Zip Code:48746-9482
Practice Address - Country:US
Practice Address - Phone:989-871-9552
Practice Address - Fax:989-871-9554
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-03
Last Update Date:2012-07-03
Deactivation Date:2006-03-21
Deactivation Code:
Reactivation Date:2006-03-29
Provider Licenses
StateLicense IDTaxonomies
MI4901003316152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4743819Medicaid
MI0P14260Medicare ID - Type Unspecified
MI4743819Medicaid