Provider Demographics
NPI:1780669499
Name:TRACEY, THOMAS NICHOLAS (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:NICHOLAS
Last Name:TRACEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1509
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78295-1509
Mailing Address - Country:US
Mailing Address - Phone:512-623-5300
Mailing Address - Fax:512-623-5399
Practice Address - Street 1:4316 JAMES CASEY ST
Practice Address - Street 2:BUILDING C
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78745-1157
Practice Address - Country:US
Practice Address - Phone:512-623-5300
Practice Address - Fax:512-623-5399
Is Sole Proprietor?:No
Enumeration Date:2005-12-14
Last Update Date:2011-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG3861207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX131767907Medicaid
TX060020153OtherMEDICARE RAILROAD
TX131767908Medicaid
TX8BX079OtherBCBSTX
P00706407OtherMEDICARE RAILROAD
TX131767902Medicaid
TX8F20668Medicare PIN
TX8BX079OtherBCBSTX
TXC22745Medicare UPIN
TX131767908Medicaid