Provider Demographics
NPI:1639304702
Name:TRACEY E PINKSTON, MD, PA
Entity Type:Organization
Organization Name:TRACEY E PINKSTON, MD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TRACEY
Authorized Official - Middle Name:E
Authorized Official - Last Name:PINKSTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:850-473-1008
Mailing Address - Street 1:4300 BAYOU BLVD
Mailing Address - Street 2:SUITE 5
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32503-1949
Mailing Address - Country:US
Mailing Address - Phone:850-473-1008
Mailing Address - Fax:850-473-1009
Practice Address - Street 1:4300 BAYOU BLVD
Practice Address - Street 2:SUITE 5
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32503-1949
Practice Address - Country:US
Practice Address - Phone:850-473-1008
Practice Address - Fax:850-473-1009
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-19
Last Update Date:2009-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLHCC7432261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center