Healthcare Provider Details

I. General information

NPI: 1104916246
Provider Name (Legal Business Name): TRACY LYNN LUDDEN OD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/12/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

912 W STATE ST
OLEAN NY
14760-2242
US

IV. Provider business mailing address

116 BRADLEY DR
OLEAN NY
14760-3948
US

V. Phone/Fax

Practice location:
  • Phone: 716-373-0766
  • Fax: 716-373-1275
Mailing address:
  • Phone: 716-373-6031
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberT005716
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOE007844
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier01608566
Identifier TypeMEDICAID
Identifier StateNY
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: