Provider Demographics
NPI:1124229380
Name:TRACY, MICHAEL KENNEDY (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:KENNEDY
Last Name:TRACY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6183 PASEO DEL NORTE STE 290
Mailing Address - Street 2:
Mailing Address - City:CARLSBAD
Mailing Address - State:CA
Mailing Address - Zip Code:92011-1151
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6183 PASEO DEL NORTE STE 290
Practice Address - Street 2:
Practice Address - City:CARLSBAD
Practice Address - State:CA
Practice Address - Zip Code:92011-1151
Practice Address - Country:US
Practice Address - Phone:760-603-9910
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-29
Last Update Date:2018-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC54009207W00000X, 207W00000X
MI4301093408207W00000X
NV13656207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1124229380Medicaid
OH9310794Medicaid
OH9310791Medicaid
OH9310793Medicaid
MI1124229380Medicaid
OH9310794Medicaid
OH1064600002Medicare NSC
OH9310793Medicaid
OH4255342Medicare PIN
OH4255343Medicare PIN