Provider Demographics
NPI:1104828714
Name:GODFREY, TRACY ALAINE (MD)
Entity Type:Individual
Prefix:MS
First Name:TRACY
Middle Name:ALAINE
Last Name:GODFREY
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 1:6151 N MAIN STREET RD
Mailing Address - Street 2:
Mailing Address - City:WEBB CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64870-8189
Mailing Address - Country:US
Mailing Address - Phone:417-781-0408
Mailing Address - Fax:417-556-5377
Practice Address - Street 1:6151 N MAIN STREET RD
Practice Address - Street 2:
Practice Address - City:WEBB CITY
Practice Address - State:MO
Practice Address - Zip Code:64870-8189
Practice Address - Country:US
Practice Address - Phone:417-781-0408
Practice Address - Fax:417-556-5377
Is Sole Proprietor?:No
Enumeration Date:2005-08-12
Last Update Date:2016-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO115438207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100179800AMedicaid
KS100405220DMedicaid
MO204685424Medicaid
MOMA2082066Medicare PIN
MO204685424Medicaid