Provider Demographics
NPI:1699847384
Name:TRACY, LIBBI (OD)
Entity Type:Individual
Prefix:
First Name:LIBBI
Middle Name:
Last Name:TRACY
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:LIBBI
Other - Middle Name:
Other - Last Name:TARDIBUONO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:1626 E KENWOOD ST
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85203-2151
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1121 S GILBERT RD
Practice Address - Street 2:SUITE 103
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85204-5235
Practice Address - Country:US
Practice Address - Phone:480-854-3310
Practice Address - Fax:480-854-1157
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2016-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ767152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZDB1051OtherRAILROAD MEDICARE GROUP ID
AZP00086938OtherRAILROAD MEDICARE PIN
AZU52154Medicare UPIN
AZZ189471Medicare PIN