Provider Demographics
NPI:1043485949
Name:PAUL TRACY OD
Entity Type:Organization
Organization Name:PAUL TRACY OD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:D
Authorized Official - Last Name:TRACY
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:573-406-1503
Mailing Address - Street 1:2316 BRIAR LN
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:IL
Mailing Address - Zip Code:62305-6574
Mailing Address - Country:US
Mailing Address - Phone:816-645-8025
Mailing Address - Fax:573-406-1057
Practice Address - Street 1:3650 STARDUST DR
Practice Address - Street 2:
Practice Address - City:HANNIBAL
Practice Address - State:MO
Practice Address - Zip Code:63401-2480
Practice Address - Country:US
Practice Address - Phone:573-406-1503
Practice Address - Fax:573-406-1057
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-23
Last Update Date:2012-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2001020432152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO39941018OtherBLUECROSS BLUE SHIELD
MO39941018OtherBLUECROSS BLUE SHIELD
MOMA1025Medicare UPIN