Provider Demographics
NPI:1184075608
Name:DECKER, MATTHEW LAURENCE (OD)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:LAURENCE
Last Name:DECKER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:881 USS JAMES MADISON RD
Mailing Address - Street 2:
Mailing Address - City:KINGS BAY
Mailing Address - State:GA
Mailing Address - Zip Code:31547-2531
Mailing Address - Country:US
Mailing Address - Phone:912-573-4227
Mailing Address - Fax:
Practice Address - Street 1:881 USS JAMES MADISON RD BAY
Practice Address - Street 2:
Practice Address - City:KINGS BAY
Practice Address - State:GA
Practice Address - Zip Code:31547-2531
Practice Address - Country:US
Practice Address - Phone:912-573-4227
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-27
Last Update Date:2021-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004997152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4901004997OtherMICHIGAN DEPARTMENT OF LICENSING AND REGULATORY AFFAIRS
OHT6926OtherOHIO VISION PROFESSIONALS BOARD