Provider Demographics
NPI:1619911757
Name:ANDERSON, TRACI A (DO)
Entity Type:Individual
Prefix:
First Name:TRACI
Middle Name:A
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6626 E. 75TH STREET
Mailing Address - Street 2:SUITE 500
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-2890
Mailing Address - Country:US
Mailing Address - Phone:765-298-4569
Mailing Address - Fax:765-298-4568
Practice Address - Street 1:1251 HUNTZINGER BLVD STE 100
Practice Address - Street 2:
Practice Address - City:PENDLETON
Practice Address - State:IN
Practice Address - Zip Code:46064-9404
Practice Address - Country:US
Practice Address - Phone:765-298-4567
Practice Address - Fax:765-298-4568
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34008676207Q00000X
IN02003246A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00474998OtherRAILROAD MEDICARE
INP01018446OtherRR MEDICARE
IN000000527527OtherANTHEM
IN000000527527OtherANTHEM
IN221220BMedicare PIN