Provider Demographics
NPI:1619967957
Name:KOTNIK, TRACY ANN (MD, FAAFP)
Entity Type:Individual
Prefix:DR
First Name:TRACY
Middle Name:ANN
Last Name:KOTNIK
Suffix:
Gender:F
Credentials:MD, FAAFP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3218 WOODRIDGE AVE NW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44718-3448
Mailing Address - Country:US
Mailing Address - Phone:330-456-5472
Mailing Address - Fax:
Practice Address - Street 1:2859 AARONWOOD AVE NE
Practice Address - Street 2:UNIT 3
Practice Address - City:MASSILLON
Practice Address - State:OH
Practice Address - Zip Code:44646-2371
Practice Address - Country:US
Practice Address - Phone:330-832-2280
Practice Address - Fax:330-832-4732
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-27
Last Update Date:2010-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35062187K207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0936205Medicaid
OH0936205Medicaid
OHKO0740856Medicare ID - Type Unspecified