Provider Demographics
NPI:1114033826
Name:DAVENPORT, TRACEY M (MD)
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:M
Last Name:DAVENPORT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:TRACEY
Other - Middle Name:
Other - Last Name:ALQASEM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1333 BUTTERFIELD RD
Mailing Address - Street 2:STE 130
Mailing Address - City:DOWNERS GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60515-5641
Mailing Address - Country:US
Mailing Address - Phone:630-371-0133
Mailing Address - Fax:630-371-0138
Practice Address - Street 1:7301 N LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:LINCOLNWOOD
Practice Address - State:IL
Practice Address - Zip Code:60712-1709
Practice Address - Country:US
Practice Address - Phone:224-766-7669
Practice Address - Fax:847-674-0892
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2018-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-114303207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK22131Medicare PIN