Provider Demographics
NPI:1699943688
Name:DR TRACEY J SHAFFER, OPTOMETRIST PLC
Entity type:Organization
Organization Name:DR TRACEY J SHAFFER, OPTOMETRIST PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TRACEY
Authorized Official - Middle Name:J
Authorized Official - Last Name:SHAFFER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:757-456-5550
Mailing Address - Street 1:705 ERIK PAUL DR
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23322-3717
Mailing Address - Country:US
Mailing Address - Phone:757-456-5550
Mailing Address - Fax:757-456-0091
Practice Address - Street 1:4588 VIRGINIA BEACH BLVD
Practice Address - Street 2:CARE OF SEARS OPTICAL
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23462-3004
Practice Address - Country:US
Practice Address - Phone:757-456-5550
Practice Address - Fax:757-456-0091
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-13
Last Update Date:2010-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618000633152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1457371502Medicaid
VAU75937Medicare UPIN
VAC10381Medicare PIN