Provider Demographics
NPI:1174672778
Name:BALL, TRACEI DENISE (MD)
Entity Type:Individual
Prefix:DR
First Name:TRACEI
Middle Name:DENISE
Last Name:BALL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6428 W WILKINSON BLVD
Mailing Address - Street 2:SUITE 241
Mailing Address - City:BELMONT
Mailing Address - State:NC
Mailing Address - Zip Code:28012-2858
Mailing Address - Country:US
Mailing Address - Phone:313-303-7493
Mailing Address - Fax:
Practice Address - Street 1:6428 W WILKINSON BLVD
Practice Address - Street 2:SUITE 241
Practice Address - City:BELMONT
Practice Address - State:NC
Practice Address - Zip Code:28012-2858
Practice Address - Country:US
Practice Address - Phone:313-303-7493
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-10
Last Update Date:2012-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301078262207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5916671Medicaid