Provider Demographics
NPI:1902835499
Name:DEXTER-EAVES, TRACEY DIANE (OD)
Entity Type:Individual
Prefix:DR
First Name:TRACEY
Middle Name:DIANE
Last Name:DEXTER-EAVES
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:TRACEY
Other - Middle Name:DIANE
Other - Last Name:DEXTER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:209 W 15TH ST
Mailing Address - Street 2:
Mailing Address - City:HOPKINSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42240-2035
Mailing Address - Country:US
Mailing Address - Phone:270-886-8129
Mailing Address - Fax:270-886-4773
Practice Address - Street 1:209 W 15TH ST
Practice Address - Street 2:
Practice Address - City:HOPKINSVILLE
Practice Address - State:KY
Practice Address - Zip Code:42240-2035
Practice Address - Country:US
Practice Address - Phone:270-886-8129
Practice Address - Fax:270-886-4773
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2020-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1343 DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY77001238Medicaid
KY000000232416OtherANTHEM BCBS
KY9356701Medicare ID - Type Unspecified
KY000000232416OtherANTHEM BCBS