Provider Demographics
NPI:1386883403
Name:EICKHOFF, TRACY ANN (OD)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:ANN
Last Name:EICKHOFF
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 1:3510 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LEAGUE CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77573-1733
Mailing Address - Country:US
Mailing Address - Phone:281-724-3040
Mailing Address - Fax:281-724-3041
Practice Address - Street 1:3510 W MAIN ST
Practice Address - Street 2:
Practice Address - City:LEAGUE CITY
Practice Address - State:TX
Practice Address - Zip Code:77573-1733
Practice Address - Country:US
Practice Address - Phone:281-724-3040
Practice Address - Fax:281-724-3041
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-12
Last Update Date:2013-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX7252TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX112409104Medicaid
TX00E63GMedicare UPIN
TXTXB160111Medicare PIN