Provider Demographics
NPI:1528023637
Name:TRACY, EMERSON RICHARDS (OPTOMETRIC PHYSICIAN)
Entity Type:Individual
Prefix:DR
First Name:EMERSON
Middle Name:RICHARDS
Last Name:TRACY
Suffix:
Gender:M
Credentials:OPTOMETRIC PHYSICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3000 W. BRIGANTINE AVE
Mailing Address - Street 2:
Mailing Address - City:BRIGANTINE
Mailing Address - State:NJ
Mailing Address - Zip Code:08203-1704
Mailing Address - Country:US
Mailing Address - Phone:609-266-3553
Mailing Address - Fax:609-266-4131
Practice Address - Street 1:3000 W BRIGANTINE AVENUE
Practice Address - Street 2:
Practice Address - City:BRIGANTINE
Practice Address - State:NJ
Practice Address - Zip Code:08203
Practice Address - Country:US
Practice Address - Phone:609-266-3553
Practice Address - Fax:609-266-4131
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-20
Last Update Date:2012-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ2704152W00000X
NJ#2704152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1273205Medicaid
U23990Medicare UPIN
NJU23990Medicare UPIN
NJ0623760001Medicare NSC
067937Medicare PIN
NJ1273205Medicaid