Provider Demographics
NPI:1912605999
Name:BARTHOLOMEW, TRACEY
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:
Last Name:BARTHOLOMEW
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2016 MILLENNIUM BLVD
Mailing Address - Street 2:
Mailing Address - City:CORTLAND
Mailing Address - State:OH
Mailing Address - Zip Code:44410-9173
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2016 MILLENNIUM BLVD
Practice Address - Street 2:
Practice Address - City:CORTLAND
Practice Address - State:OH
Practice Address - Zip Code:44410-9173
Practice Address - Country:US
Practice Address - Phone:330-372-2210
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-20
Last Update Date:2023-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC6973156FX1800X
OHSC6973156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician