Provider Demographics
NPI:1356308266
Name:TRACY, BRIAN D (OD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:D
Last Name:TRACY
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3000 L ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95816-5248
Mailing Address - Country:US
Mailing Address - Phone:916-454-5729
Mailing Address - Fax:
Practice Address - Street 1:3000 L ST
Practice Address - Street 2:SUITE 100
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95816-5248
Practice Address - Country:US
Practice Address - Phone:916-454-5729
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-26
Last Update Date:2012-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9109T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA46598OtherSAFEGUARD VISION
CA211188OtherEYEMED
CA00E630000OtherDMERC SIGNA
CA02338OtherMEDICAL EYE SERVICES
CASD0091090Medicaid
CA410012517OtherRAILROAD MEDICARE
CA34392OtherDAVIS VISION
CA00E630000OtherDMERC SIGNA
CA02338OtherMEDICAL EYE SERVICES