Provider Demographics
NPI:1811023054
Name:GISH, TRACY L (OD)
Entity Type:Individual
Prefix:DR
First Name:TRACY
Middle Name:L
Last Name:GISH
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 1:5600 S 59TH ST
Mailing Address - Street 2:SUITE 105
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68516-2386
Mailing Address - Country:US
Mailing Address - Phone:402-328-8811
Mailing Address - Fax:402-328-8813
Practice Address - Street 1:5600 S 59TH ST
Practice Address - Street 2:SUITE 105
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68516-2386
Practice Address - Country:US
Practice Address - Phone:402-328-8811
Practice Address - Fax:402-328-8813
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE986152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE6943OtherBLUE CROSS
277859Medicare ID - Type Unspecified
NE6943OtherBLUE CROSS
NET89786Medicare UPIN