Provider Demographics
NPI:1467434647
Name:KOCEMBA, TRACY LYNN (OD)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:LYNN
Last Name:KOCEMBA
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:TRACY
Other - Middle Name:LYNN
Other - Last Name:SCOTT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:15936 US HIGHWAY 63
Mailing Address - Street 2:
Mailing Address - City:HAYWARD
Mailing Address - State:WI
Mailing Address - Zip Code:54843-7162
Mailing Address - Country:US
Mailing Address - Phone:715-634-1028
Mailing Address - Fax:715-634-9733
Practice Address - Street 1:15936 US HIGHWAY 63
Practice Address - Street 2:
Practice Address - City:HAYWARD
Practice Address - State:WI
Practice Address - Zip Code:54843-7162
Practice Address - Country:US
Practice Address - Phone:715-634-1028
Practice Address - Fax:715-634-9733
Is Sole Proprietor?:No
Enumeration Date:2005-11-15
Last Update Date:2009-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2684-035152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38600700Medicaid
P00069305OtherPALMETTO RR MEDICARE
874300004OtherMEDICARE AT INDIANHEAD
P00069305OtherPALMETTO RR MEDICARE
U67782Medicare UPIN
000147845Medicare PIN