Provider Demographics
NPI:1407871684
Name:WARREN, JOHN TRACY (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:TRACY
Last Name:WARREN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 POND VIEW DR
Mailing Address - Street 2:
Mailing Address - City:JERICHO
Mailing Address - State:VT
Mailing Address - Zip Code:05465-2030
Mailing Address - Country:US
Mailing Address - Phone:920-246-6288
Mailing Address - Fax:
Practice Address - Street 1:11 POND VIEW DR
Practice Address - Street 2:
Practice Address - City:JERICHO
Practice Address - State:VT
Practice Address - Zip Code:05465-2030
Practice Address - Country:US
Practice Address - Phone:920-435-1503
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2022-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI29771207Q00000X
WI29771-020207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI31516000Medicaid
E09567Medicare UPIN
07125-0125Medicare ID - Type Unspecified