Provider Demographics
NPI:1851314108
Name:BURROUGHS, TRICIA MICHELLE (OD)
Entity Type:Individual
Prefix:MRS
First Name:TRICIA
Middle Name:MICHELLE
Last Name:BURROUGHS
Suffix:
Gender:F
Credentials:OD
Other - Prefix:MRS
Other - First Name:TRICIA
Other - Middle Name:MICHELLE
Other - Last Name:BOWERSOCK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:81 E GAY STREET
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43215-3103
Mailing Address - Country:US
Mailing Address - Phone:614-224-2414
Mailing Address - Fax:614-224-5916
Practice Address - Street 1:6732 PERIMETER LOOP ROAD
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:OH
Practice Address - Zip Code:43017-3202
Practice Address - Country:US
Practice Address - Phone:614-798-9940
Practice Address - Fax:614-798-9913
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5176152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2256062Medicaid
OHBU4050891Medicare ID - Type Unspecified
OH2256062Medicaid