Provider Demographics
NPI:1700991916
Name:DOLL, TRACY CHANTELLLE (OD)
Entity Type:Individual
Prefix:DR
First Name:TRACY
Middle Name:CHANTELLLE
Last Name:DOLL
Suffix:
Gender:F
Credentials:OD
Other - Prefix:MRS
Other - First Name:TRACY
Other - Middle Name:CHANTELLE
Other - Last Name:LEE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:17184 SW ARTESIAN DR
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97006-4990
Mailing Address - Country:US
Mailing Address - Phone:503-314-5856
Mailing Address - Fax:
Practice Address - Street 1:3710 SW US VETERANS HOSPITAL RD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-2964
Practice Address - Country:US
Practice Address - Phone:503-220-8262
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3184ATI152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist