Provider Demographics
NPI:1285628289
Name:WELLS, TRACY C (OD)
Entity Type:Individual
Prefix:DR
First Name:TRACY
Middle Name:C
Last Name:WELLS
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 1:4092 AUSTIN BLUFFS PKWY
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80918-5905
Mailing Address - Country:US
Mailing Address - Phone:719-590-1765
Mailing Address - Fax:719-590-9603
Practice Address - Street 1:4092 AUSTIN BLUFFS PKWY
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80918-5905
Practice Address - Country:US
Practice Address - Phone:719-590-1765
Practice Address - Fax:719-590-9603
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1420152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
COU84381Medicare UPIN