Provider Demographics
NPI:1982628897
Name:DECKELBAUM, GENA WORLEY (OD)
Entity Type:Individual
Prefix:MRS
First Name:GENA
Middle Name:WORLEY
Last Name:DECKELBAUM
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:GENA
Other - Middle Name:MARIE
Other - Last Name:DECKELBAUM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:2 PILLSBURY ST STE 100
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NH
Mailing Address - Zip Code:03301-3549
Mailing Address - Country:US
Mailing Address - Phone:603-224-2020
Mailing Address - Fax:
Practice Address - Street 1:2 PILLSBURY ST STE 100
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NH
Practice Address - Zip Code:03301-3549
Practice Address - Country:US
Practice Address - Phone:603-224-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2024-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH1093152W00000X
FLOPC3963152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL620942400Medicaid
FL620942400Medicaid