Provider Demographics
NPI:1942207014
Name:PITTMAN, TRACY B (MD)
Entity Type:Individual
Prefix:DR
First Name:TRACY
Middle Name:B
Last Name:PITTMAN
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 1:12 MARKS RD
Mailing Address - Street 2:
Mailing Address - City:OCEAN SPRINGS
Mailing Address - State:MS
Mailing Address - Zip Code:39564-4350
Mailing Address - Country:US
Mailing Address - Phone:228-872-6329
Mailing Address - Fax:228-872-7758
Practice Address - Street 1:12 MARKS RD
Practice Address - Street 2:
Practice Address - City:OCEAN SPRINGS
Practice Address - State:MS
Practice Address - Zip Code:39564-4350
Practice Address - Country:US
Practice Address - Phone:228-872-6329
Practice Address - Fax:228-872-7758
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSMS12531207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00117495Medicaid
MSF77894Medicare UPIN