Provider Demographics
NPI:1578751491
Name:TRACY, PAUL DAVID (OD)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:DAVID
Last Name:TRACY
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2316 BRIAR LN
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:IL
Mailing Address - Zip Code:62305-6574
Mailing Address - Country:US
Mailing Address - Phone:816-645-8025
Mailing Address - Fax:573-406-1057
Practice Address - Street 1:1025 MAINE ST
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:IL
Practice Address - Zip Code:62301-4038
Practice Address - Country:US
Practice Address - Phone:217-222-6550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-04
Last Update Date:2014-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2001020432152W00000X
IL046010425152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOMA1025001Medicare PIN
MOMA1025001Medicare UPIN
ILF400131515Medicare PIN