Provider Demographics
NPI:1356404008
Name:YOTHERS, TRACEY L (OD)
Entity type:Individual
Prefix:DR
First Name:TRACEY
Middle Name:L
Last Name:YOTHERS
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 1:7306 BLACKWILLOW LN
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75249-1430
Mailing Address - Country:US
Mailing Address - Phone:972-298-7249
Mailing Address - Fax:972-298-6740
Practice Address - Street 1:535 W WHEATLAND RD
Practice Address - Street 2:
Practice Address - City:DUNCANVILLE
Practice Address - State:TX
Practice Address - Zip Code:75116-4515
Practice Address - Country:US
Practice Address - Phone:972-298-7249
Practice Address - Fax:972-298-6740
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-17
Last Update Date:2010-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX05168TG152W00000X, 152WC0802X, 152WP0200X, 152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00E52GOtherGROUP BCBS NUMBER
TX176941601Medicaid
TXT13054OtherINDIVIDUAL BCBS
TX021948OtherBLOCK MEDICAID LOCAT #
TX040972404Medicaid
TX921409OtherINDIVIDUAL BLOCK MEDICAID
TXT13054OtherINDIVIDUAL BCBS
TXT13054Medicare UPIN
TX00E52GMedicare UPIN
TX00E52GMedicare ID - Type UnspecifiedGROUP MEDICARE NUMB