Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 152W00000X | Optometrist | TA1597 | MD |
NPI | 1003801077 |
---|---|
Provider Name | Tracie M King |
First Address | Elkridge, MD 21075-5440 |
Second Address | Elkridge, MD 21075-5440 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 15/09/2005 |
Last Update Date | 10/02/2009 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
U85115 | (02) | MD |