Basic Information
| Provider Information | |||||||||
| NPI: | 1003801077 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KING | ||||||||
| FirstName: | TRACIE | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7310 ESQUIRE CT STE 3 | ||||||||
| Address2: | BAY FAMILY EYE CARE | ||||||||
| City: | ELKRIDGE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210755440 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4107964555 | ||||||||
| FaxNumber: | 4107968606 | ||||||||
| Practice Location | |||||||||
| Address1: | 7310 ESQUIRE CT STE 3 | ||||||||
| Address2: | BAY FAMILY EYE CARE | ||||||||
| City: | ELKRIDGE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210755440 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4107964555 | ||||||||
| FaxNumber: | 4107968606 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/15/2005 | ||||||||
| LastUpdateDate: | 02/10/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | TA1597 | MD | Y | Eye and Vision Services Providers | Optometrist |
No ID Information.