1235314600 NPI number — BRIAN D TRACY, OD

Table of content: (NPI 1235314600)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235314600 NPI number — BRIAN D TRACY, OD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BRIAN D TRACY, OD
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1235314600
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/12/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3000 L ST
Provider Second Line Business Mailing Address:
STE 100
Provider Business Mailing Address City Name:
SACRAMENTO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95816-5248
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
916-454-5729
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3000 L ST
Provider Second Line Business Practice Location Address:
STE 100
Provider Business Practice Location Address City Name:
SACRAMENTO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95816-5248
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
916-454-5729
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/04/2008

Additional Information

Authorized Official

Authorized Official Last Name:
TRACY
Authorized Official First Name:
BRIAN
Authorized Official Middle Name:
D
Authorized Official Title or Position:
OPTOMETRIST
Authorized Official Telephone Number:
916-454-5729

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  9109T , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 206384 . This is a "COLE VISION" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 211188 . This is a "EYEMED" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 0536300001 . This is a "DMERC CIGNA" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 34392 . This is a "DAVIS VISION" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 02338 . This is a "MEDICAL EYE SERVICES" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 410012517 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 45457 . This is a "SPECTERA VISION" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: GSD004430 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 46598 . This is a "SAFEGUARD VISION HMO" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 49282 . This is a "SAFEGUARD VISION PPO" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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