Provider Demographics
NPI:1437314127
Name:CLARK, TRACEY DURKOVICH (DO)
Entity Type:Individual
Prefix:DR
First Name:TRACEY
Middle Name:DURKOVICH
Last Name:CLARK
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:TRACEY
Other - Middle Name:ERIN
Other - Last Name:DURKOVICH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:1 RIDGEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401
Mailing Address - Country:US
Mailing Address - Phone:207-945-6200
Mailing Address - Fax:207-990-3015
Practice Address - Street 1:1 RIDGEWOOD DRIVE
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401
Practice Address - Country:US
Practice Address - Phone:207-945-6200
Practice Address - Fax:207-990-3015
Is Sole Proprietor?:No
Enumeration Date:2008-07-23
Last Update Date:2013-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOT012459207W00000X
ME2313207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology