Provider Demographics
NPI:1497867733
Name:MAYO, TRACY TODA (OD)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:TODA
Last Name:MAYO
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:TRACY
Other - Middle Name:ANN
Other - Last Name:TODA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:477 E COLORADO BLVD
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91101-2024
Mailing Address - Country:US
Mailing Address - Phone:626-796-1191
Mailing Address - Fax:626-796-0189
Practice Address - Street 1:477 E COLORADO BLVD
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91101-2024
Practice Address - Country:US
Practice Address - Phone:626-796-1191
Practice Address - Fax:626-796-0189
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA7524T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0075240Medicaid
CASD0075240Medicaid
CAWOP7524BMedicare PIN