Provider Demographics
NPI:1285669895
Name:BRITO, TRACY C (MD)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:C
Last Name:BRITO
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 1:3401 N PERRYVILLE RD
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61114-8011
Mailing Address - Country:US
Mailing Address - Phone:815-971-2000
Mailing Address - Fax:815-971-9447
Practice Address - Street 1:3401 N PERRYVILLE RD
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61114-8011
Practice Address - Country:US
Practice Address - Phone:815-971-2000
Practice Address - Fax:815-971-9447
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2016-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036074111207R00000X, 202K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes202K00000XAllopathic & Osteopathic PhysiciansPhlebology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILF400269517OtherMEDICARE PTAN
ILF400269517OtherMEDICARE PTAN
ILK06351Medicare ID - Type Unspecified