Healthcare Provider Details

I. General information

NPI: 1801891403
Provider Name (Legal Business Name): TRACEY C BOSS O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2005
Last Update Date: 02/14/2022
Certification Date: 02/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31519 WINTERPLACE PKWY STE 1
SALISBURY MD
21804-1884
US

IV. Provider business mailing address

31519 WINTERPLACE PKWY STE 1
SALISBURY MD
21804-1884
US

V. Phone/Fax

Practice location:
  • Phone: 410-546-2500
  • Fax: 410-546-5005
Mailing address:
  • Phone: 410-546-2500
  • Fax: 410-546-5005

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number0006064UVT
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number13-0001320
License Number StateDE
# 3
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License Number0006064UVT
License Number StateNY
# 4
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberTA2027
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: