Provider Demographics
NPI:1508179854
Name:TOMJACK, TRACY BETH (DO)
Entity Type:Individual
Prefix:DR
First Name:TRACY
Middle Name:BETH
Last Name:TOMJACK
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:709 4TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:WATFORD CITY
Mailing Address - State:ND
Mailing Address - Zip Code:58854-7628
Mailing Address - Country:US
Mailing Address - Phone:701-444-8730
Mailing Address - Fax:
Practice Address - Street 1:709 4TH AVE NE
Practice Address - Street 2:
Practice Address - City:WATFORD CITY
Practice Address - State:ND
Practice Address - Zip Code:58854-7628
Practice Address - Country:US
Practice Address - Phone:701-444-8730
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-15
Last Update Date:2019-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD9080207Q00000X
NDPT 13097207Q00000X
ND13097207Q00000X, 207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine