Provider Demographics
NPI:1215135611
Name:SHOEMAKER, TRACY L (OD)
Entity type:Individual
Prefix:DR
First Name:TRACY
Middle Name:L
Last Name:SHOEMAKER
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:TRACY
Other - Middle Name:L
Other - Last Name:GARDEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:4008 S ELM PL
Mailing Address - Street 2:STE A
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74011
Mailing Address - Country:US
Mailing Address - Phone:918-455-2020
Mailing Address - Fax:918-455-4030
Practice Address - Street 1:4008 S ELM PL
Practice Address - Street 2:STE A
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74011
Practice Address - Country:US
Practice Address - Phone:918-455-2020
Practice Address - Fax:918-455-4030
Is Sole Proprietor?:No
Enumeration Date:2007-07-06
Last Update Date:2024-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD00004159152W00000X
OK2837152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2034155Medicaid
OK200617840AMedicaid