Provider Demographics
NPI:1043257835
Name:TRGOVAC, TRACEY L (MD)
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:L
Last Name:TRGOVAC
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 1:4885 OLENTANGY RIVER RD
Mailing Address - Street 2:SUITE 110
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43214-1952
Mailing Address - Country:US
Mailing Address - Phone:614-268-6555
Mailing Address - Fax:614-457-5706
Practice Address - Street 1:4885 OLENTANGY RIVER RD
Practice Address - Street 2:SUITE 110
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43214-1952
Practice Address - Country:US
Practice Address - Phone:614-268-6555
Practice Address - Fax:614-457-5706
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-01
Last Update Date:2013-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35075473207R00000X
OH35.075473208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2247563Medicaid
OHH203770Medicare PIN