Provider Demographics
NPI:1841381597
Name:TRACY, DIANA M (MD)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:M
Last Name:TRACY
Suffix:
Gender:F
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 3008
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62902-3008
Mailing Address - Country:US
Mailing Address - Phone:618-457-0450
Mailing Address - Fax:618-457-7329
Practice Address - Street 1:1250 CEDAR CT
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-5334
Practice Address - Country:US
Practice Address - Phone:618-351-1213
Practice Address - Fax:618-351-1905
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2010-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0361134712084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry