Provider Demographics
NPI:1033121892
Name:TRACY, DAVID P (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:P
Last Name:TRACY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1530 PINE GROVE AVE
Mailing Address - Street 2:STE 7
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060
Mailing Address - Country:US
Mailing Address - Phone:810-985-0029
Mailing Address - Fax:810-985-0032
Practice Address - Street 1:1530 PINE GROVE AVE
Practice Address - Street 2:STE 7
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060
Practice Address - Country:US
Practice Address - Phone:810-985-0029
Practice Address - Fax:810-985-0032
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI0665782085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4094810Medicaid
G13985Medicare UPIN