Provider Demographics
NPI:1760560205
Name:MILLER, TRACY ANN (OD)
Entity Type:Individual
Prefix:DR
First Name:TRACY
Middle Name:ANN
Last Name:MILLER
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 1:711 INDEPENDENCE VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81507-9575
Mailing Address - Country:US
Mailing Address - Phone:970-250-7071
Mailing Address - Fax:
Practice Address - Street 1:2472 PATTERSON RD
Practice Address - Street 2:UNIT 11
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81505-1076
Practice Address - Country:US
Practice Address - Phone:970-424-5555
Practice Address - Fax:970-424-5027
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2012-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2523152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO11713642OtherCAQH ID
U44884Medicare UPIN