Provider Demographics
NPI:1447385802
Name:MONTIERTH, TRACY JON (OD)
Entity Type:Individual
Prefix:DR
First Name:TRACY
Middle Name:JON
Last Name:MONTIERTH
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 1:1502 S 1ST AVE STE 8
Mailing Address - Street 2:
Mailing Address - City:SAFFORD
Mailing Address - State:AZ
Mailing Address - Zip Code:85546-2143
Mailing Address - Country:US
Mailing Address - Phone:928-428-4360
Mailing Address - Fax:928-424-4361
Practice Address - Street 1:1502 S 1ST AVE STE 8
Practice Address - Street 2:
Practice Address - City:SAFFORD
Practice Address - State:AZ
Practice Address - Zip Code:85546-2143
Practice Address - Country:US
Practice Address - Phone:928-428-4360
Practice Address - Fax:928-424-4361
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-23
Last Update Date:2013-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ776152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZOD776Medicare PIN
AZT91302Medicare UPIN
AZ0591170001Medicare NSC