Provider Demographics
NPI:1134298516
Name:CRANE, TRACY L (OD)
Entity Type:Individual
Prefix:DR
First Name:TRACY
Middle Name:L
Last Name:CRANE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:TRACY
Other - Middle Name:L
Other - Last Name:HOLLINGSHEAD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:210 E WATER ST
Mailing Address - Street 2:
Mailing Address - City:PENDLETON
Mailing Address - State:IN
Mailing Address - Zip Code:46064-1047
Mailing Address - Country:US
Mailing Address - Phone:765-778-7524
Mailing Address - Fax:
Practice Address - Street 1:210 E WATER ST
Practice Address - Street 2:
Practice Address - City:PENDLETON
Practice Address - State:IN
Practice Address - Zip Code:46064-1047
Practice Address - Country:US
Practice Address - Phone:765-778-7524
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2012-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18003198B152W00000X
AZ1646152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ755382Medicaid
AZ8HBF31Medicare ID - Type UnspecifiedMEDICARE PROVIDER#
AZ755382Medicaid