Provider Demographics
NPI:1861400517
Name:SPONSELLER, TRACIE L (OD)
Entity type:Individual
Prefix:DR
First Name:TRACIE
Middle Name:L
Last Name:SPONSELLER
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 1:3152 WASHINGTON RD
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30907-3891
Mailing Address - Country:US
Mailing Address - Phone:706-651-1291
Mailing Address - Fax:706-210-8090
Practice Address - Street 1:3152 WASHINGTON RD
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30907-3891
Practice Address - Country:US
Practice Address - Phone:706-651-1291
Practice Address - Fax:706-210-8090
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-04
Last Update Date:2014-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT002160152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA329735702CMedicaid
GA329735702AMedicaid
GA511I410014Medicare PIN
GAU18822Medicare UPIN
GA41ZCFVWMedicare PIN