Provider Demographics
NPI:1033119953
Name:LAWRENCE-BLACK, TRACY (MD)
Entity Type:Individual
Prefix:DR
First Name:TRACY
Middle Name:
Last Name:LAWRENCE-BLACK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:53 STONEWALL CIR
Mailing Address - Street 2:
Mailing Address - City:WEST HARRISON
Mailing Address - State:NY
Mailing Address - Zip Code:10604-1126
Mailing Address - Country:US
Mailing Address - Phone:240-205-0861
Mailing Address - Fax:
Practice Address - Street 1:95 BRADHURST AVE
Practice Address - Street 2:
Practice Address - City:VALHALLA
Practice Address - State:NY
Practice Address - Zip Code:10595-1637
Practice Address - Country:US
Practice Address - Phone:914-592-7555
Practice Address - Fax:866-310-5326
Is Sole Proprietor?:No
Enumeration Date:2005-07-22
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC336442080N0001X
CT0538082080N0001X
NY2818822080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC011625G65Medicare PIN
H83793Medicare UPIN