Provider Demographics
NPI:1275587495
Name:RAYKOVICZ, TRACY MACINTYRE (OD)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:MACINTYRE
Last Name:RAYKOVICZ
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 1:815 DEERCROSS LN
Mailing Address - Street 2:
Mailing Address - City:WAXHAW
Mailing Address - State:NC
Mailing Address - Zip Code:28173-6603
Mailing Address - Country:US
Mailing Address - Phone:704-847-7474
Mailing Address - Fax:
Practice Address - Street 1:2115 W ROOSEVELT BLVD
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:NC
Practice Address - Zip Code:28110-2737
Practice Address - Country:US
Practice Address - Phone:704-238-1849
Practice Address - Fax:704-238-1850
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCNC1894152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD98478700Medicaid
U76659Medicare UPIN
MD98478700Medicaid