Provider Demographics
NPI:1699882324
Name:SCHMALLE-JACOBS, TRACI L S (OD)
Entity type:Individual
Prefix:
First Name:TRACI
Middle Name:L S
Last Name:SCHMALLE-JACOBS
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:TRACI
Other - Middle Name:L
Other - Last Name:SCHMALLE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:94-348 LELEAKA ST
Mailing Address - Street 2:
Mailing Address - City:MILILANI
Mailing Address - State:HI
Mailing Address - Zip Code:96789-2213
Mailing Address - Country:US
Mailing Address - Phone:808-455-5650
Mailing Address - Fax:808-455-5625
Practice Address - Street 1:1131 KUALA STREET
Practice Address - Street 2:C/O THE VISION CENTER
Practice Address - City:PEARL CITY
Practice Address - State:HI
Practice Address - Zip Code:96782
Practice Address - Country:US
Practice Address - Phone:808-455-5650
Practice Address - Fax:808-455-5625
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI594152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI101283Medicare ID - Type Unspecified
HIU85978Medicare UPIN