Provider Demographics
NPI:1700107729
Name:DECENZO-VERBETEN, TERESA MARIE (OD)
Entity type:Individual
Prefix:DR
First Name:TERESA
Middle Name:MARIE
Last Name:DECENZO-VERBETEN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5135 WILD GINGER CV
Mailing Address - Street 2:
Mailing Address - City:NORCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:30092-5145
Mailing Address - Country:US
Mailing Address - Phone:678-415-3513
Mailing Address - Fax:678-415-3815
Practice Address - Street 1:11460 JOHNS CREEK PKWY
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30097-1518
Practice Address - Country:US
Practice Address - Phone:678-415-3513
Practice Address - Fax:678-415-3815
Is Sole Proprietor?:No
Enumeration Date:2010-06-14
Last Update Date:2010-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT001643152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist