Provider Demographics
NPI:1235103664
Name:DALY-WILSON, TRACEY M (MD)
Entity Type:Individual
Prefix:DR
First Name:TRACEY
Middle Name:M
Last Name:DALY-WILSON
Suffix:
Gender:F
Credentials:MD
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Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:12348 OLD TESSON RD
Mailing Address - Street 2:SUITE 160
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63128-2215
Mailing Address - Country:US
Mailing Address - Phone:314-467-3800
Mailing Address - Fax:314-467-3801
Practice Address - Street 1:12348 OLD TESSON RD
Practice Address - Street 2:SUITE 160
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63128-2215
Practice Address - Country:US
Practice Address - Phone:314-467-3800
Practice Address - Fax:314-467-3801
Is Sole Proprietor?:No
Enumeration Date:2006-02-14
Last Update Date:2012-02-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MO108525208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
H27291Medicare UPIN