Provider Demographics
NPI:1346356862
Name:SANFORD, TRACY SMITH (DO)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:SMITH
Last Name:SANFORD
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1151 S BELMONT AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:OKMULGEE
Mailing Address - State:OK
Mailing Address - Zip Code:74447-6307
Mailing Address - Country:US
Mailing Address - Phone:918-759-2200
Mailing Address - Fax:918-759-2206
Practice Address - Street 1:1151 S BELMONT AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:OKMULGEE
Practice Address - State:OK
Practice Address - Zip Code:74447-6307
Practice Address - Country:US
Practice Address - Phone:918-759-2200
Practice Address - Fax:918-759-2206
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-21
Last Update Date:2008-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3598207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK080194475OtherRAILROAD MEDICARE
OK100223390BMedicaid
OK080194475OtherRAILROAD MEDICARE
OK249734003Medicare PIN