Provider Demographics
NPI:1255524005
Name:SCOTT, TRACY (OD)
Entity type:Individual
Prefix:DR
First Name:TRACY
Middle Name:
Last Name:SCOTT
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:TRACY
Other - Middle Name:
Other - Last Name:QUANDT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:403 E PECK RD
Mailing Address - Street 2:
Mailing Address - City:PECK
Mailing Address - State:MI
Mailing Address - Zip Code:48466-9755
Mailing Address - Country:US
Mailing Address - Phone:810-705-5351
Mailing Address - Fax:
Practice Address - Street 1:454 W SANILAC RD
Practice Address - Street 2:
Practice Address - City:SANDUSKY
Practice Address - State:MI
Practice Address - Zip Code:48471-1065
Practice Address - Country:US
Practice Address - Phone:810-648-2020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-24
Last Update Date:2013-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004451152W00000X
WV1055-OD152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist