Provider Demographics
NPI:1992753206
Name:DECKER, ELYSE M (OD)
Entity type:Individual
Prefix:DR
First Name:ELYSE
Middle Name:M
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 1:911 MIDWAY
Mailing Address - Street 2:
Mailing Address - City:WOODMERE
Mailing Address - State:NY
Mailing Address - Zip Code:11598-1526
Mailing Address - Country:US
Mailing Address - Phone:516-295-2810
Mailing Address - Fax:
Practice Address - Street 1:4101 BELL BLVD
Practice Address - Street 2:
Practice Address - City:BAYSIDE
Practice Address - State:NY
Practice Address - Zip Code:11361-2858
Practice Address - Country:US
Practice Address - Phone:718-428-6700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2014-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006919152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02666815Medicaid
NY02666815Medicaid
NY07245Medicare ID - Type UnspecifiedGHI MEDICARE
NYC415H1Medicare ID - Type UnspecifiedEMPIRE MEDICARE