Provider Demographics
NPI:1144633702
Name:BRACKLEY, TARA (OD)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:BRACKLEY
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 1:6221 STATE ROUTE 31
Mailing Address - Street 2:SUITE 104
Mailing Address - City:CICERO
Mailing Address - State:NY
Mailing Address - Zip Code:13039-8715
Mailing Address - Country:US
Mailing Address - Phone:315-752-0141
Mailing Address - Fax:315-752-0142
Practice Address - Street 1:4000 MEDICAL CENTER DR
Practice Address - Street 2:SUITE 207
Practice Address - City:FAYETTEVILLE
Practice Address - State:NY
Practice Address - Zip Code:13066-6631
Practice Address - Country:US
Practice Address - Phone:315-637-1010
Practice Address - Fax:315-637-2010
Is Sole Proprietor?:No
Enumeration Date:2014-06-11
Last Update Date:2014-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV008116152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYTUV008116OtherNYS LICENSE