Provider Demographics
NPI:1346432614
Name:CORDRAY, TRACY LEIGH (MD)
Entity Type:Individual
Prefix:DR
First Name:TRACY
Middle Name:LEIGH
Last Name:CORDRAY
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 1:2093 HENRY TECKLENBURG DR STE 340
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29414-5741
Mailing Address - Country:US
Mailing Address - Phone:843-718-2334
Mailing Address - Fax:843-277-2067
Practice Address - Street 1:2093 HENRY TECKLENBURG DR STE 340
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29414-5741
Practice Address - Country:US
Practice Address - Phone:843-718-2334
Practice Address - Fax:843-277-2067
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-10
Last Update Date:2022-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA79618208200000X
SC221852086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
No208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC813653106OtherTAX ID
SC1346432614OtherINDIVIDUAL NPI
SCSC5037G677OtherMEDICARE PTAN
SC30236309Medicaid