Provider Demographics
NPI:1578662342
Name:BIGELOW, TRACY LEE (DO)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:LEE
Last Name:BIGELOW
Suffix:
Gender:F
Credentials:DO
Other - Prefix:DR
Other - First Name:TRACY
Other - Middle Name:M
Other - Last Name:LEE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:600 COFFEE RD
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95355-4201
Mailing Address - Country:US
Mailing Address - Phone:209-521-6097
Mailing Address - Fax:
Practice Address - Street 1:2545 W HAMMER LN
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95209-2839
Practice Address - Country:US
Practice Address - Phone:209-957-7050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2015-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A 11567207XS0106X
CA20A11567207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand Surgery
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH34008758OtherOHIO MEDICAL LICENSE
CA20A 11567OtherCALIFORNIA OSTEOPATHIC MEDICAL LICENSE
OH2671158Medicaid
OHBI4190793Medicare PIN
OHBI4190794Medicare PIN
CA20A 11567OtherCALIFORNIA OSTEOPATHIC MEDICAL LICENSE
OHBI4190792Medicare PIN