Provider Demographics
NPI:1376767079
Name:ANDERSON, TRACY JOSEPH (MD)
Entity Type:Individual
Prefix:DR
First Name:TRACY
Middle Name:JOSEPH
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:TRACY
Other - Middle Name:JOSEPH
Other - Last Name:GIESSMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:WEINGARTL 15
Mailing Address - Street 2:
Mailing Address - City:NATTERS
Mailing Address - State:TIROL
Mailing Address - Zip Code:6161
Mailing Address - Country:AT
Mailing Address - Phone:208-450-2011
Mailing Address - Fax:
Practice Address - Street 1:200 HAWKINS DR
Practice Address - Street 2:
Practice Address - City:IOWA CITY
Practice Address - State:IA
Practice Address - Zip Code:52242-1007
Practice Address - Country:US
Practice Address - Phone:208-450-2011
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-12
Last Update Date:2010-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-8414207L00000X
AZ32547207L00000X
FLME-89192207L00000X
CO42192207L00000X
IA37627207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO10178066Medicaid
IAP00461644Medicare PIN
CO10178066Medicaid
COCOA100952Medicare PIN
IAI0923009Medicare PIN