Provider Demographics
NPI:1962014225
Name:LUKASIEWICZ, TRACY (OD)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:LUKASIEWICZ
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 1:220 N MCKEMY AVE
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85226-2651
Mailing Address - Country:US
Mailing Address - Phone:480-961-1865
Mailing Address - Fax:
Practice Address - Street 1:2222 E CAMELBACK RD STE 250M
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-3427
Practice Address - Country:US
Practice Address - Phone:602-840-3501
Practice Address - Fax:602-840-3671
Is Sole Proprietor?:No
Enumeration Date:2020-08-18
Last Update Date:2021-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG003716152W00000X
AZOPT-002510152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist