Provider Demographics
NPI:1265500383
Name:EKHARDT, TRACY L (MD)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:L
Last Name:EKHARDT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:TRACY
Other - Middle Name:L
Other - Last Name:STEPHENSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1200 PLEASANT ST
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50309-1406
Mailing Address - Country:US
Mailing Address - Phone:515-241-5926
Mailing Address - Fax:515-241-5127
Practice Address - Street 1:1200 PLEASANT ST
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50309-1406
Practice Address - Country:US
Practice Address - Phone:515-241-5926
Practice Address - Fax:515-241-5127
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2016-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA368202080P0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0203XAllopathic & Osteopathic PhysiciansPediatricsPediatric Critical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1265500383Medicaid
NE100264995-00Medicaid
NE100264995-00Medicaid