Basic Information
| Provider Information | |||||||||
| NPI: | 1578751491 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TRACY | ||||||||
| FirstName: | PAUL | ||||||||
| MiddleName: | DAVID | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2316 BRIAR LN | ||||||||
| Address2: | |||||||||
| City: | QUINCY | ||||||||
| State: | IL | ||||||||
| PostalCode: | 623056574 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8166458025 | ||||||||
| FaxNumber: | 5734061057 | ||||||||
| Practice Location | |||||||||
| Address1: | 1025 MAINE ST | ||||||||
| Address2: | |||||||||
| City: | QUINCY | ||||||||
| State: | IL | ||||||||
| PostalCode: | 623014038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2172226550 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2007 | ||||||||
| LastUpdateDate: | 05/01/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 2001020432 | MO | N | Eye and Vision Services Providers | Optometrist | 152W00000X | 046010425 | IL | Y | Eye and Vision Services Providers | Optometrist |
No ID Information.