Provider Demographics
NPI:1528210838
Name:BRADY, TRACY D (MD)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:D
Last Name:BRADY
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 1:2675 WINKLER AVE FL 2
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33901-9342
Mailing Address - Country:US
Mailing Address - Phone:508-627-6048
Mailing Address - Fax:850-862-8156
Practice Address - Street 1:203 CLOVERDALE BLVD
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547-1405
Practice Address - Country:US
Practice Address - Phone:850-862-7604
Practice Address - Fax:850-862-8156
Is Sole Proprietor?:No
Enumeration Date:2008-10-17
Last Update Date:2022-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60945861207Q00000X
MI4301088426207Q00000X
FLME154970207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2128705Medicaid
MI3036262Medicaid
000000628417OtherANTHEM
WA2128705Medicaid
MI3036262Medicaid
P00752925OtherRRMC