Provider Demographics
NPI:1457561060
Name:DECKER, LARRY W (OD)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:W
Last Name:DECKER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2311 S JEFFERSON AVE
Mailing Address - Street 2:SUITE 20/20
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:TX
Mailing Address - Zip Code:75455-6011
Mailing Address - Country:US
Mailing Address - Phone:903-577-8946
Mailing Address - Fax:903-577-8951
Practice Address - Street 1:2311 S JEFFERSON AVE
Practice Address - Street 2:SUITE 20/20
Practice Address - City:MOUNT PLEASANT
Practice Address - State:TX
Practice Address - Zip Code:75455-6011
Practice Address - Country:US
Practice Address - Phone:903-577-8946
Practice Address - Fax:903-577-8951
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-23
Last Update Date:2010-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX4731TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX019181901Medicaid
TX019181901Medicaid