Provider Demographics
NPI:1053341701
Name:ASMUS, TRACEY LYNN (OD)
Entity type:Individual
Prefix:DR
First Name:TRACEY
Middle Name:LYNN
Last Name:ASMUS
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:TRACEY
Other - Middle Name:LYNN
Other - Last Name:ASMUS LOMBARDI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OD
Mailing Address - Street 1:27 FOXTAIL RD
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457-1770
Mailing Address - Country:US
Mailing Address - Phone:860-632-8735
Mailing Address - Fax:
Practice Address - Street 1:2691 BERLIN TPKE
Practice Address - Street 2:
Practice Address - City:NEWINGTON
Practice Address - State:CT
Practice Address - Zip Code:06111-4114
Practice Address - Country:US
Practice Address - Phone:860-594-4585
Practice Address - Fax:860-667-4377
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2012-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002561152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT11241145OtherCAQH
CT11241145OtherCAQH
CTU62986Medicare UPIN