Provider Demographics
NPI:1538413588
Name:ROBERT E. DECK, III O.D., PC
Entity type:Organization
Organization Name:ROBERT E. DECK, III O.D., PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:E
Authorized Official - Last Name:DECK III
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:248-693-2321
Mailing Address - Street 1:81 INDIANWOOD RD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:LAKE ORION
Mailing Address - State:MI
Mailing Address - Zip Code:48362-1595
Mailing Address - Country:US
Mailing Address - Phone:248-693-2321
Mailing Address - Fax:248-693-2703
Practice Address - Street 1:81 INDIANWOOD RD
Practice Address - Street 2:SUITE 1
Practice Address - City:LAKE ORION
Practice Address - State:MI
Practice Address - Zip Code:48362-1595
Practice Address - Country:US
Practice Address - Phone:248-693-2321
Practice Address - Fax:248-693-2703
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-30
Last Update Date:2012-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003566152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI900F36558OtherBLUE CROSS BLUE SHIELD
MI943240332Medicaid
MI943240332Medicaid