Provider Demographics
NPI:1881855807
Name:HENDERSHOT, TRACY (MD)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:HENDERSHOT
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 609
Mailing Address - Street 2:
Mailing Address - City:ELIZABETH
Mailing Address - State:WV
Mailing Address - Zip Code:26143-0609
Mailing Address - Country:US
Mailing Address - Phone:304-275-3301
Mailing Address - Fax:304-275-4798
Practice Address - Street 1:1301 ELIZABETH PIKE
Practice Address - Street 2:
Practice Address - City:ELIZABETH
Practice Address - State:WV
Practice Address - Zip Code:26143-0609
Practice Address - Country:US
Practice Address - Phone:304-275-3301
Practice Address - Fax:304-275-4798
Is Sole Proprietor?:No
Enumeration Date:2008-06-23
Last Update Date:2022-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV23784207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV23784Medicare PIN