Provider Demographics
NPI:1477787026
Name:RIVERA, TRACIE B (MD)
Entity Type:Individual
Prefix:DR
First Name:TRACIE
Middle Name:B
Last Name:RIVERA
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 1:100 BENEVITA PL APT 303
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23666-1073
Mailing Address - Country:US
Mailing Address - Phone:304-216-6783
Mailing Address - Fax:
Practice Address - Street 1:UNITED SUMMIT CENTER
Practice Address - Street 2:6 HOSPITAL PLAZA
Practice Address - City:CLARKSBURG
Practice Address - State:WV
Practice Address - Zip Code:26301-2604
Practice Address - Country:US
Practice Address - Phone:304-623-2989
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-12
Last Update Date:2023-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01012616042084P0800X
WV249502084P0800X
390200000X
KY477842084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program