Provider Demographics
NPI:1104976760
Name:BURROUGHS, TRACY D (OD)
Entity type:Individual
Prefix:DR
First Name:TRACY
Middle Name:D
Last Name:BURROUGHS
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:806 LANDMARK DR
Mailing Address - Street 2:STE 114
Mailing Address - City:GLEN BURNIE
Mailing Address - State:MD
Mailing Address - Zip Code:21061-4966
Mailing Address - Country:US
Mailing Address - Phone:410-526-4162
Mailing Address - Fax:
Practice Address - Street 1:806 LANDMARK DR
Practice Address - Street 2:SUITE 114
Practice Address - City:GLEN BURNIE
Practice Address - State:MD
Practice Address - Zip Code:21061-4980
Practice Address - Country:US
Practice Address - Phone:410-590-9260
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-12
Last Update Date:2017-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDTA1304152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist