Provider Demographics
NPI:1619011863
Name:ASHLOCK, TRACY LYNN (OD)
Entity Type:Individual
Prefix:DR
First Name:TRACY
Middle Name:LYNN
Last Name:ASHLOCK
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 1:1313 SOLANO AVE
Mailing Address - Street 2:ALBANY
Mailing Address - City:ALBANY
Mailing Address - State:CA
Mailing Address - Zip Code:94706-1825
Mailing Address - Country:US
Mailing Address - Phone:510-526-0194
Mailing Address - Fax:
Practice Address - Street 1:1313 SOLANO AVE
Practice Address - Street 2:ALBANY
Practice Address - City:ALBANY
Practice Address - State:CA
Practice Address - Zip Code:94706-1825
Practice Address - Country:US
Practice Address - Phone:510-526-0194
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT 12691 TPA152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0126910Medicaid
CAV01435Medicare UPIN
CASD0126910Medicaid