Provider Demographics
NPI:1710368782
Name:MEDRANO- SMITH, TRACIE (DO)
Entity Type:Individual
Prefix:
First Name:TRACIE
Middle Name:
Last Name:MEDRANO- SMITH
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4288 3 MILE RD NW
Mailing Address - Street 2:
Mailing Address - City:WALKER
Mailing Address - State:MI
Mailing Address - Zip Code:49534-7596
Mailing Address - Country:US
Mailing Address - Phone:616-458-3677
Mailing Address - Fax:
Practice Address - Street 1:4174 56TH ST SW
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:MI
Practice Address - Zip Code:49418
Practice Address - Country:US
Practice Address - Phone:616-458-3677
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-15
Last Update Date:2019-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101021683207Q00000X
MI5315069986208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine