Provider Demographics
NPI:1871025973
Name:MODESTE, TRACEY MELISSA
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:MELISSA
Last Name:MODESTE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TRACEY
Other - Middle Name:MELLISA
Other - Last Name:GAFF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:64 ROBBINS STREET
Mailing Address - Street 2:WATERBURY HOSPITAL,
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06708
Mailing Address - Country:US
Mailing Address - Phone:203-573-6162
Mailing Address - Fax:203-573-6707
Practice Address - Street 1:305 CHURCH ST STE 15
Practice Address - Street 2:
Practice Address - City:NAUGATUCK
Practice Address - State:CT
Practice Address - Zip Code:06770-2836
Practice Address - Country:US
Practice Address - Phone:203-729-6641
Practice Address - Fax:203-575-5206
Is Sole Proprietor?:No
Enumeration Date:2017-03-29
Last Update Date:2022-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CT66924207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program