MEDICARE: TRACY LYNN KOCEMBA OD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	2684-035	WI

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	P00069305	OTHER		PALMETTO RR MEDICARE
3	874300004	OTHER		MEDICARE AT INDIANHEAD

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1467434647
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TRACY LYNN KOCEMBA OD

Provider Business Mailing Address
First Line	:	15936 US HIGHWAY 63
Second Line	:
City	:	HAYWARD
State	:	WI
Zip	:	54843-7162
Country	:	US
Telephone Number	:	715-634-1028
Fax Number	:	715-634-9733

Provider Business Practice Location Address
First Line	:	15936 US HIGHWAY 63
Second Line	:
City	:	HAYWARD
State	:	WI
Zip	:	54843-7162
Country	:	US
Telephone Number	:	715-634-1028
Fax Number	:	715-634-9733

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/15/2005
Last Update Date	:	02/23/2009

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Directions to “ TRACY LYNN KOCEMBA OD” Practice Location

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