Provider Demographics
NPI:1639108673
Name:TRACZYK, RICHARD JOSEPH (DPM)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:JOSEPH
Last Name:TRACZYK
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3818 N ROCKWELL AVE
Mailing Address - Street 2:
Mailing Address - City:BETHANY
Mailing Address - State:OK
Mailing Address - Zip Code:73008-3350
Mailing Address - Country:US
Mailing Address - Phone:405-787-8820
Mailing Address - Fax:405-495-6523
Practice Address - Street 1:3818 N ROCKWELL AVE
Practice Address - Street 2:
Practice Address - City:BETHANY
Practice Address - State:OK
Practice Address - Zip Code:73008-3350
Practice Address - Country:US
Practice Address - Phone:405-787-8820
Practice Address - Fax:405-495-6523
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-02
Last Update Date:2008-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK104213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
1255250001OtherDMERC
OKT40775Medicare UPIN
1255250001Medicare NSC