Provider Demographics
NPI:1891878690
Name:TRACY, BRIAN D (OD)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:D
Last Name:TRACY
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 1:141 CLINT DR
Mailing Address - Street 2:
Mailing Address - City:PICKERINGTON
Mailing Address - State:OH
Mailing Address - Zip Code:43147-7750
Mailing Address - Country:US
Mailing Address - Phone:614-575-0111
Mailing Address - Fax:614-577-9214
Practice Address - Street 1:141 CLINT DR
Practice Address - Street 2:
Practice Address - City:PICKERINGTON
Practice Address - State:OH
Practice Address - Zip Code:43147-7750
Practice Address - Country:US
Practice Address - Phone:614-575-0111
Practice Address - Fax:614-577-9214
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2014-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4686152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2010282Medicaid
OHTR0793403Medicare ID - Type Unspecified
T69293Medicare UPIN