Provider Demographics
NPI:1316983398
Name:DECKER, MARIANNE RAE (OD)
Entity type:Individual
Prefix:
First Name:MARIANNE
Middle Name:RAE
Last Name:DECKER
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 1:1947 FERN ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92102-1137
Mailing Address - Country:US
Mailing Address - Phone:619-233-6183
Mailing Address - Fax:619-232-7415
Practice Address - Street 1:1947 FERN ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92102-1137
Practice Address - Country:US
Practice Address - Phone:619-233-6183
Practice Address - Fax:619-232-7415
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA06018-T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0060180Medicaid
CASD0060180Medicaid
CAT70080Medicare UPIN