Provider Demographics
NPI:1275651952
Name:DECKER, MARYANN KATHLEEN (OPTOMETRIST)
Entity Type:Individual
Prefix:DR
First Name:MARYANN
Middle Name:KATHLEEN
Last Name:DECKER
Suffix:
Gender:F
Credentials:OPTOMETRIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:522 ROCKY GLEN RD
Mailing Address - Street 2:
Mailing Address - City:AVOCA
Mailing Address - State:PA
Mailing Address - Zip Code:18641-9508
Mailing Address - Country:US
Mailing Address - Phone:570-457-0437
Mailing Address - Fax:
Practice Address - Street 1:PEARLE VISION 820 SCRANTON CARBONDALE HIGHWAY
Practice Address - Street 2:EYNON PLAZA
Practice Address - City:EYNON
Practice Address - State:PA
Practice Address - Zip Code:18403
Practice Address - Country:US
Practice Address - Phone:570-876-5050
Practice Address - Fax:570-876-3526
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG001325152W00000X, 152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered152W00000XEye and Vision Services ProvidersOptometrist
Not Answered152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA563034Medicare ID - Type UnspecifiedOPTOMETRY