Provider Demographics
NPI:1720038441
Name:MALSOM, TRACIE (OD)
Entity Type:Individual
Prefix:
First Name:TRACIE
Middle Name:
Last Name:MALSOM
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 1:1695 43RD ST S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-3317
Mailing Address - Country:US
Mailing Address - Phone:701-235-3937
Mailing Address - Fax:701-356-3937
Practice Address - Street 1:1695 43RD ST S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-3317
Practice Address - Country:US
Practice Address - Phone:701-235-3937
Practice Address - Fax:701-356-3937
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2013-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18003360152W00000X
ND642152W00000X
MN3046152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
INU 08603Medicare UPIN