Provider Demographics
NPI:1679556872
Name:KAWAMURA, TRACY CAROL (OD)
Entity type:Individual
Prefix:DR
First Name:TRACY
Middle Name:CAROL
Last Name:KAWAMURA
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3200 N SEPULVEDA BLVD
Mailing Address - Street 2:STE E4
Mailing Address - City:MANHATTAN BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90266-2469
Mailing Address - Country:US
Mailing Address - Phone:310-939-9926
Mailing Address - Fax:
Practice Address - Street 1:3500 N SEPULVEDA BLVD
Practice Address - Street 2:SUITE E4
Practice Address - City:MANHATTAN BEACH
Practice Address - State:CA
Practice Address - Zip Code:90266-3638
Practice Address - Country:US
Practice Address - Phone:310-546-5568
Practice Address - Fax:310-546-5421
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-22
Last Update Date:2020-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9750TPA152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0097500Medicaid
CASD0097500Medicaid
U27478Medicare UPIN