Provider Demographics
NPI:1245234103
Name:DECKER, BOBBY (OD)
Entity Type:Individual
Prefix:DR
First Name:BOBBY
Middle Name:
Last Name:DECKER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:813 W CENTRAL AVE
Mailing Address - Street 2:SUITE 5
Mailing Address - City:BENTONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72712-5787
Mailing Address - Country:US
Mailing Address - Phone:479-855-0009
Mailing Address - Fax:479-876-7105
Practice Address - Street 1:813 W CENTRAL AVE
Practice Address - Street 2:SUITE 5
Practice Address - City:BENTONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72712-5787
Practice Address - Country:US
Practice Address - Phone:479-855-0009
Practice Address - Fax:479-876-7105
Is Sole Proprietor?:No
Enumeration Date:2005-06-09
Last Update Date:2013-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2518152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR145384722Medicaid
AR49777Medicare ID - Type Unspecified
AR145384722Medicaid