Provider Demographics
NPI:1497738413
Name:MAYBERRY, TRACY SMITH (DPM)
Entity Type:Individual
Prefix:DR
First Name:TRACY
Middle Name:SMITH
Last Name:MAYBERRY
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:DR
Other - First Name:TRACY
Other - Middle Name:ALETTA
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPM
Mailing Address - Street 1:1683 WASHINGTON ROAD
Mailing Address - Street 2:
Mailing Address - City:EAST POINT
Mailing Address - State:GA
Mailing Address - Zip Code:30344-4265
Mailing Address - Country:US
Mailing Address - Phone:404-766-6400
Mailing Address - Fax:404-766-6450
Practice Address - Street 1:1683 WASHINGTON RD
Practice Address - Street 2:
Practice Address - City:EAST POINT
Practice Address - State:GA
Practice Address - Zip Code:30344-4265
Practice Address - Country:US
Practice Address - Phone:404-766-6400
Practice Address - Fax:404-766-6450
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-23
Last Update Date:2021-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPOD000763213EP1101X, 213ER0200X, 213ES0000X, 213ES0103X, 213ES0131X
GA000763213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
No213ER0200XPodiatric Medicine & Surgery Service ProvidersPodiatristRadiology
No213ES0000XPodiatric Medicine & Surgery Service ProvidersPodiatristSports Medicine
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA480028687OtherRAILROAD MEDICARE
GA000672119FMedicaid
GA480028687OtherRAILROAD MEDICARE
GAU57852Medicare UPIN