Provider Demographics
NPI:1114230935
Name:DONAHUE, TRACY L (MD)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:L
Last Name:DONAHUE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MISS
Other - First Name:TRACY
Other - Middle Name:L
Other - Last Name:FUHRMANN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:788 N JEFFERSON ST
Mailing Address - Street 2:SUITE 300/ATTN. KAAREN BUTZEN
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53202-3718
Mailing Address - Country:US
Mailing Address - Phone:414-272-8950
Mailing Address - Fax:414-272-0859
Practice Address - Street 1:2350 N LAKE DR
Practice Address - Street 2:SUITE 300
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53211-4528
Practice Address - Country:US
Practice Address - Phone:414-298-7100
Practice Address - Fax:414-298-7101
Is Sole Proprietor?:No
Enumeration Date:2010-07-21
Last Update Date:2016-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI65911207N00000X
IL036135708207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1114230935Medicaid
WIK40321321Medicare UPIN