Provider Demographics
NPI:1427040492
Name:DECLEENE, CATHERINE M (OD)
Entity type:Individual
Prefix:DR
First Name:CATHERINE
Middle Name:M
Last Name:DECLEENE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:KATE
Other - Middle Name:M
Other - Last Name:DECLEEENE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OD
Mailing Address - Street 1:608 E BOULEVARD
Mailing Address - Street 2:
Mailing Address - City:KOKOMO
Mailing Address - State:IN
Mailing Address - Zip Code:46902-2286
Mailing Address - Country:US
Mailing Address - Phone:765-453-5005
Mailing Address - Fax:765-453-8937
Practice Address - Street 1:608 E BOULEVARD
Practice Address - Street 2:
Practice Address - City:KOKOMO
Practice Address - State:IN
Practice Address - Zip Code:46902-2286
Practice Address - Country:US
Practice Address - Phone:765-453-5005
Practice Address - Fax:765-453-8937
Is Sole Proprietor?:No
Enumeration Date:2005-08-16
Last Update Date:2014-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18002524A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100341590Medicaid
IN0657090001Medicare NSC
INU44698Medicare UPIN
IN100341590Medicaid