Provider Demographics
NPI:1053455295
Name:KOHM, TRACI LYNNE (OD)
Entity Type:Individual
Prefix:
First Name:TRACI
Middle Name:LYNNE
Last Name:KOHM
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:TRACI
Other - Middle Name:LYNNE
Other - Last Name:HAHN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9549 WATSON ROAD
Mailing Address - Street 2:
Mailing Address - City:ST. LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63126
Mailing Address - Country:US
Mailing Address - Phone:314-651-3883
Mailing Address - Fax:
Practice Address - Street 1:9549 WATSON ROAD
Practice Address - Street 2:
Practice Address - City:ST. LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63126
Practice Address - Country:US
Practice Address - Phone:314-651-3883
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-19
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006017275152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOMA1595030OtherMEDICARE ID
MOMA1595030OtherMEDICARE ID
MOV11573Medicare UPIN
MO964934545Medicare PIN