Provider Demographics
NPI:1578837134
Name:SAMKO, TRACEY (MD)
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:
Last Name:SAMKO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 N STATE ST
Mailing Address - Street 2:CT -A7D
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90033-1029
Mailing Address - Country:US
Mailing Address - Phone:323-226-7556
Mailing Address - Fax:323-226-2657
Practice Address - Street 1:1200 N STATE ST
Practice Address - Street 2:CT -A7D
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90033-1029
Practice Address - Country:US
Practice Address - Phone:323-226-7556
Practice Address - Fax:323-226-2657
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-29
Last Update Date:2018-05-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA124169207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA113906OtherSID # 113906