Provider Demographics
NPI:1639162704
Name:THOMPSON, TRACY L
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:L
Last Name:THOMPSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:525 S WILSON ST
Mailing Address - Street 2:
Mailing Address - City:VINITA
Mailing Address - State:OK
Mailing Address - Zip Code:74301-4646
Mailing Address - Country:US
Mailing Address - Phone:918-323-0191
Mailing Address - Fax:918-323-0081
Practice Address - Street 1:525 S WILSON ST
Practice Address - Street 2:
Practice Address - City:VINITA
Practice Address - State:OK
Practice Address - Zip Code:74301-4646
Practice Address - Country:US
Practice Address - Phone:918-323-0191
Practice Address - Fax:918-323-0081
Is Sole Proprietor?:No
Enumeration Date:2005-08-24
Last Update Date:2011-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKOK3319207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK8EZ04VMedicare ID - Type Unspecified
OKG13692Medicare UPIN