Provider Demographics
NPI:1437177342
Name:DECK, ROBERT EMMETT III (OD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:EMMETT
Last Name:DECK
Suffix:III
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 1:81 INDIANWOOD RD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:LAKE ORION
Mailing Address - State:MI
Mailing Address - Zip Code:48362-1595
Mailing Address - Country:US
Mailing Address - Phone:248-693-2321
Mailing Address - Fax:
Practice Address - Street 1:81 INDIANWOOD RD
Practice Address - Street 2:SUITE 1
Practice Address - City:LAKE ORION
Practice Address - State:MI
Practice Address - Zip Code:48362-1595
Practice Address - Country:US
Practice Address - Phone:248-693-2321
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2009-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003566152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI324-0332Medicaid
MIU35377Medicare UPIN
MI1079310001Medicare NSC
MIOG46543Medicare ID - Type Unspecified