Provider Demographics
NPI:1659363489
Name:LADD, TRACI AURELIA (MD)
Entity Type:Individual
Prefix:
First Name:TRACI
Middle Name:AURELIA
Last Name:LADD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:TRACI
Other - Middle Name:LADD
Other - Last Name:LAMOTHE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:704-384-1950
Mailing Address - Fax:704-384-1955
Practice Address - Street 1:14215 BALLANTYNE CORPORATE PARK
Practice Address - Street 2:SUITE 130
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28277
Practice Address - Country:US
Practice Address - Phone:704-384-1950
Practice Address - Fax:704-384-1955
Is Sole Proprietor?:No
Enumeration Date:2005-08-18
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9901431208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCN01437Medicaid
NC891288MMedicaid
SCN01437Medicaid