Provider Demographics
NPI:1497730303
Name:ANTILL, TRACEY A (DO)
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:A
Last Name:ANTILL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 200993
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77216-0993
Mailing Address - Country:US
Mailing Address - Phone:281-784-1111
Mailing Address - Fax:281-784-1555
Practice Address - Street 1:301 MEDIC LN
Practice Address - Street 2:
Practice Address - City:ALVIN
Practice Address - State:TX
Practice Address - Zip Code:77511-5542
Practice Address - Country:US
Practice Address - Phone:281-331-6141
Practice Address - Fax:281-331-3316
Is Sole Proprietor?:No
Enumeration Date:2005-12-13
Last Update Date:2015-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK2308207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1497730303OtherTRICARE SOUTH
TX131166408Medicaid
TX8F9296OtherBCBSTX PROV NO
TX131166409Medicaid
TX8002B9Medicare PIN
TX930121567Medicare PIN
TX8620B4Medicare PIN
TX930117292Medicare PIN
TX131166409Medicaid