Provider Demographics
NPI:1578591780
Name:MARQUIS-EYDMAN, TRACI J (MD)
Entity Type:Individual
Prefix:
First Name:TRACI
Middle Name:J
Last Name:MARQUIS-EYDMAN
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 1:2979 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06606-4284
Mailing Address - Country:US
Mailing Address - Phone:203-382-2345
Mailing Address - Fax:860-358-6748
Practice Address - Street 1:2979 MAIN ST
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06606-4284
Practice Address - Country:US
Practice Address - Phone:203-382-2345
Practice Address - Fax:860-358-6748
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2023-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT039190207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001391903Medicaid
CT001391903Medicaid
CT080001556Medicare PIN