Provider Demographics
NPI:1003801077
Name:KING, TRACIE M (OD)
Entity Type:Individual
Prefix:
First Name:TRACIE
Middle Name:M
Last Name:KING
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 1:7310 ESQUIRE CT STE 3
Mailing Address - Street 2:BAY FAMILY EYE CARE
Mailing Address - City:ELKRIDGE
Mailing Address - State:MD
Mailing Address - Zip Code:21075-5440
Mailing Address - Country:US
Mailing Address - Phone:410-796-4555
Mailing Address - Fax:410-796-8606
Practice Address - Street 1:7310 ESQUIRE CT STE 3
Practice Address - Street 2:BAY FAMILY EYE CARE
Practice Address - City:ELKRIDGE
Practice Address - State:MD
Practice Address - Zip Code:21075-5440
Practice Address - Country:US
Practice Address - Phone:410-796-4555
Practice Address - Fax:410-796-8606
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-15
Last Update Date:2023-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDTA1597152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDU85115Medicare UPIN
MD957M760FMedicare ID - Type UnspecifiedMEDICARE #