Provider Demographics
NPI:1891047056
Name:ROTH, TRACY YOUNG (MD)
Entity Type:Individual
Prefix:DR
First Name:TRACY
Middle Name:YOUNG
Last Name:ROTH
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 40480
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36640-0480
Mailing Address - Country:US
Mailing Address - Phone:251-415-1496
Mailing Address - Fax:251-415-1450
Practice Address - Street 1:1601 CENTER ST
Practice Address - Street 2:STE 3S
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36604-1512
Practice Address - Country:US
Practice Address - Phone:251-415-1496
Practice Address - Fax:251-415-1450
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-11
Last Update Date:2017-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL19526207V00000X
MS14783207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0116740Medicaid
AL009912195Medicaid
AL009912195Medicaid
160000318Medicare PIN