Provider Demographics
NPI:1922538743
Name:ISIDRO, TRACEY CONTRERAS (MD)
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:CONTRERAS
Last Name:ISIDRO
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 1:215 E 66TH ST APT 3B
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10065-6437
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:180 FORT WASHINGTON AVE STE 199
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032-3722
Practice Address - Country:US
Practice Address - Phone:212-305-3535
Practice Address - Fax:212-342-1470
Is Sole Proprietor?:No
Enumeration Date:2017-06-14
Last Update Date:2022-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY310246208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX667384OtherPIT ID NUMBER