Provider Demographics
NPI:1164454849
Name:BELLANGER, TRACIE MANUEL (MD)
Entity Type:Individual
Prefix:DR
First Name:TRACIE
Middle Name:MANUEL
Last Name:BELLANGER
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 1:606 BEAMAN ST
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:NC
Mailing Address - Zip Code:28328-2604
Mailing Address - Country:US
Mailing Address - Phone:910-596-0061
Mailing Address - Fax:910-596-0062
Practice Address - Street 1:103 COUNTRY CLUB DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28301-7603
Practice Address - Country:US
Practice Address - Phone:910-400-7002
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2023-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA24891207R00000X
NC2009-01134207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1569119Medicaid
LAH99089Medicare UPIN
LA4F642Medicare ID - Type Unspecified