Provider Demographics
NPI:1518203611
Name:MILLWOOD, TRACY MULVEHILL (OD)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:MULVEHILL
Last Name:MILLWOOD
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 1:160 GREEN ACRES BLVD
Mailing Address - Street 2:
Mailing Address - City:TRAFFORD
Mailing Address - State:AL
Mailing Address - Zip Code:35172-8782
Mailing Address - Country:US
Mailing Address - Phone:205-238-4466
Mailing Address - Fax:
Practice Address - Street 1:201 BANGOR AVE SE
Practice Address - Street 2:
Practice Address - City:HANCEVILLE
Practice Address - State:AL
Practice Address - Zip Code:35077-5645
Practice Address - Country:US
Practice Address - Phone:256-887-1550
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-17
Last Update Date:2019-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS-C91-TA-938152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL216140Medicaid