Provider Demographics
NPI:1689847063
Name:MARK S. TRACY, D.P.M., P.A.
Entity Type:Organization
Organization Name:MARK S. TRACY, D.P.M., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:S
Authorized Official - Last Name:TRACY
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:941-627-6366
Mailing Address - Street 1:3028 CARING WAY
Mailing Address - Street 2:STE 9
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33952-5300
Mailing Address - Country:US
Mailing Address - Phone:941-627-6366
Mailing Address - Fax:941-627-6677
Practice Address - Street 1:3028 CARING WAY
Practice Address - Street 2:STE 9
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33952-5300
Practice Address - Country:US
Practice Address - Phone:941-627-6366
Practice Address - Fax:941-627-6677
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-08
Last Update Date:2010-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO1878213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1962436030OtherINDIVIDUAL NPI
1962436030OtherINDIVIDUAL NPI
DE141AMedicare PIN