Provider Demographics
NPI:1073839817
Name:HENDERSON, TRACY HAMBLIN (MD)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:HAMBLIN
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:TRACY
Other - Middle Name:
Other - Last Name:HAMBLIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:110 MARY LOU DR STE 100
Mailing Address - Street 2:
Mailing Address - City:WILLOW PARK
Mailing Address - State:TX
Mailing Address - Zip Code:76087-8767
Mailing Address - Country:US
Mailing Address - Phone:817-930-2030
Mailing Address - Fax:817-757-7333
Practice Address - Street 1:110 MARY LOU DRIVE
Practice Address - Street 2:SUITE 100
Practice Address - City:WILLOW PARK
Practice Address - State:TX
Practice Address - Zip Code:76087
Practice Address - Country:US
Practice Address - Phone:817-930-2030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-19
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXT8117207RS0010X, 2081S0010X, 207QS0010X
WAMD60450293207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No207RS0010XAllopathic & Osteopathic PhysiciansInternal MedicineSports Medicine
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
No2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine