Provider Demographics
NPI:1619226255
Name:TRACY, TIFFANY NICOLE (MD)
Entity Type:Individual
Prefix:DR
First Name:TIFFANY
Middle Name:NICOLE
Last Name:TRACY
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 1:11511 SHADOW CREEK PKWY
Mailing Address - Street 2:
Mailing Address - City:PEARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:77584-7298
Mailing Address - Country:US
Mailing Address - Phone:713-442-0000
Mailing Address - Fax:
Practice Address - Street 1:17198 ST LUKES WAY
Practice Address - Street 2:SUITE 540
Practice Address - City:THE WOODLANDS
Practice Address - State:TX
Practice Address - Zip Code:77384-8011
Practice Address - Country:US
Practice Address - Phone:713-442-1900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-29
Last Update Date:2021-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXQ4864207V00000X, 207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX353701101Medicaid
TX353701103Medicaid
TX353701102Medicaid
TX436923YKTXMedicare PIN
TX436923YKTUMedicare PIN
TX353701102Medicaid