Provider Demographics
NPI:1013188754
Name:HENDERSON, TRACEY A (MD)
Entity Type:Individual
Prefix:DR
First Name:TRACEY
Middle Name:A
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:TRACEY
Other - Middle Name:ANN
Other - Last Name:PERAZONE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:200 HYGEIA DRIVE, SUITE 2300
Mailing Address - Street 2:CCHS PHYSICIAN CONTRACTING
Mailing Address - City:NEWARK
Mailing Address - State:DE
Mailing Address - Zip Code:19713-2049
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4755 OGLETOWN-STANTON ROAD
Practice Address - Street 2:MAP 1, SUITE 116
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19718-2200
Practice Address - Country:US
Practice Address - Phone:302-733-4200
Practice Address - Fax:302-733-2711
Is Sole Proprietor?:No
Enumeration Date:2008-03-21
Last Update Date:2015-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY258019208000000X
DEC1-0011343208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYJ400047607Medicare PIN