Provider Demographics
NPI:1326487588
Name:TIPTON, TRACY JON (MD)
Entity Type:Individual
Prefix:DR
First Name:TRACY
Middle Name:JON
Last Name:TIPTON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Middle Name:
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Mailing Address - Street 1:PO BOX 751649
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1649
Mailing Address - Country:US
Mailing Address - Phone:843-789-1620
Mailing Address - Fax:843-724-2440
Practice Address - Street 1:125 DOUGHTY ST STE 300
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29403
Practice Address - Country:US
Practice Address - Phone:843-884-8045
Practice Address - Fax:843-881-5081
Is Sole Proprietor?:No
Enumeration Date:2013-06-21
Last Update Date:2021-06-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
SC36003208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC9223OtherGROUP MEDICARE PTAN
SC360031Medicaid