Provider Demographics
NPI:1760789762
Name:TRACY BIGELOW, DO, INC
Entity Type:Organization
Organization Name:TRACY BIGELOW, DO, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:L
Authorized Official - Last Name:BIGELOW
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:209-524-4649
Mailing Address - Street 1:1335 COFFEE RD
Mailing Address - Street 2:STE 100
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95355-3188
Mailing Address - Country:US
Mailing Address - Phone:209-524-4649
Mailing Address - Fax:209-524-7395
Practice Address - Street 1:1335 COFFEE RD
Practice Address - Street 2:STE 100
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95355-3188
Practice Address - Country:US
Practice Address - Phone:209-524-4649
Practice Address - Fax:209-524-7395
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-28
Last Update Date:2013-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A11567207XS0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA20A 11567OtherCALIFORNIA OSTEOPATHIC MEDICAL LICENSE