Provider Demographics
NPI:1568485746
Name:MORAN, TRACY LYNN (OD)
Entity Type:Individual
Prefix:MRS
First Name:TRACY
Middle Name:LYNN
Last Name:MORAN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:MS
Other - First Name:TRACY
Other - Middle Name:LYNN
Other - Last Name:MILLS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:89 S WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48371-4979
Mailing Address - Country:US
Mailing Address - Phone:248-628-3441
Mailing Address - Fax:248-628-5105
Practice Address - Street 1:89 S WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:MI
Practice Address - Zip Code:48371-4979
Practice Address - Country:US
Practice Address - Phone:248-628-3441
Practice Address - Fax:248-628-5105
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004320152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4873840Medicaid
MI4856062OtherMEDICAID
MI4856062OtherMEDICAID
V08427Medicare UPIN
MIN26930189Medicare PIN
MI4873840Medicaid