Provider Demographics
NPI:1457371502
Name:SHAFFER, TRACEY J (OD)
Entity Type:Individual
Prefix:DR
First Name:TRACEY
Middle Name:J
Last Name:SHAFFER
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:TRACEY
Other - Middle Name:J
Other - Last Name:BARNETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:705 ERIK PAUL DR
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23322-3717
Mailing Address - Country:US
Mailing Address - Phone:757-456-5550
Mailing Address - Fax:757-456-0091
Practice Address - Street 1:4588 VIRGINIA BEACH BLVD
Practice Address - Street 2:CARE OF SEARS OPTICAL
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23462-3004
Practice Address - Country:US
Practice Address - Phone:757-456-5550
Practice Address - Fax:757-456-5550
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-20
Last Update Date:2008-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618000633152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1457371502Medicaid
VA1457371502Medicaid
VA00X595D01Medicare PIN