=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720779275
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ROBERT E DECK III, O.D., PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/16/2023
-----------------------------------------------------
Last Update Date | 05/16/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5323 E COURT ST N
-----------------------------------------------------
City | BURTON
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48509-1539
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 810-744-9596
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 93 ASCOT AVE
-----------------------------------------------------
City | WATERFORD
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48328-3503
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-701-7505
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. ROBERT EMMETT DECK III
-----------------------------------------------------
Credential | OD
-----------------------------------------------------
Telephone | 248-701-7505
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------