Provider Demographics
NPI:1396730719
Name:LE, TRACY THAO (OD)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:THAO
Last Name:LE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:THAO
Other - Middle Name:PHUONG
Other - Last Name:LE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3331 NORWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95148-2712
Mailing Address - Country:US
Mailing Address - Phone:408-259-1818
Mailing Address - Fax:408-259-1871
Practice Address - Street 1:301 N JACKSON AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95133-2344
Practice Address - Country:US
Practice Address - Phone:408-259-1818
Practice Address - Fax:408-259-1871
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT11478T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0114780Medicaid
CASD0114780Medicaid