Provider Demographics
NPI:1467681874
Name:DECOURSEY, JOHN WARREN (OD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:WARREN
Last Name:DECOURSEY
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 1:223 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:VINCENNES
Mailing Address - State:IN
Mailing Address - Zip Code:47591-1208
Mailing Address - Country:US
Mailing Address - Phone:812-882-4809
Mailing Address - Fax:812-882-9485
Practice Address - Street 1:223 MAIN ST
Practice Address - Street 2:
Practice Address - City:VINCENNES
Practice Address - State:IN
Practice Address - Zip Code:47591-1208
Practice Address - Country:US
Practice Address - Phone:812-882-4809
Practice Address - Fax:812-882-9485
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-07
Last Update Date:2022-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18003581A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201098530Medicaid