Provider Demographics
NPI:1669634739
Name:TRACY, MAHKAMEH GHADIMI (MD)
Entity Type:Individual
Prefix:DR
First Name:MAHKAMEH
Middle Name:GHADIMI
Last Name:TRACY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MAHKAMEH
Other - Middle Name:
Other - Last Name:GHADIMI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10350 E DAKOTA AVE
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80247-1314
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4318 TRAIL BOSS DR STE 100
Practice Address - Street 2:
Practice Address - City:CASTLE ROCK
Practice Address - State:CO
Practice Address - Zip Code:80104-7512
Practice Address - Country:US
Practice Address - Phone:303-338-4545
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-30
Last Update Date:2021-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.0050393207QA0000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QA0000XAllopathic & Osteopathic PhysiciansFamily MedicineAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO58422757Medicaid
CO029172OtherKAIASER COMMERCIAL NUMBER