Provider Demographics
NPI:1073688206
Name:RAY, TRACY P (OD)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:P
Last Name:RAY
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 896189
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28289-6189
Mailing Address - Country:US
Mailing Address - Phone:843-664-9393
Mailing Address - Fax:
Practice Address - Street 1:3911 MAIN ST
Practice Address - Street 2:
Practice Address - City:LORIS
Practice Address - State:SC
Practice Address - Zip Code:29569-3017
Practice Address - Country:US
Practice Address - Phone:843-756-1262
Practice Address - Fax:843-756-6667
Is Sole Proprietor?:No
Enumeration Date:2006-11-22
Last Update Date:2024-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC860152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCDA9737Medicaid
SCT23757Medicare UPIN
1316890001Medicare NSC
SCT237570281Medicare PIN