Provider Demographics
NPI:1053452110
Name:TATE, TRACY (OD)
Entity Type:Individual
Prefix:DR
First Name:TRACY
Middle Name:
Last Name:TATE
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 1:5300 CORNERSTONE NORTH BLVD
Mailing Address - Street 2:
Mailing Address - City:CENTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45440-2268
Mailing Address - Country:US
Mailing Address - Phone:937-640-6015
Mailing Address - Fax:937-640-6016
Practice Address - Street 1:5300 CORNERSTONE NORTH BLVD
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:45440-2268
Practice Address - Country:US
Practice Address - Phone:937-640-6015
Practice Address - Fax:937-640-6016
Is Sole Proprietor?:No
Enumeration Date:2007-02-10
Last Update Date:2017-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5244 T2148152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist