Provider Demographics
NPI:1942423892
Name:TRACY, RICHARD EDWARD (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:EDWARD
Last Name:TRACY
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 1:1401 S UNIVERSITY DR
Mailing Address - Street 2:P. O. BOX 632040
Mailing Address - City:NACOGDOCHES
Mailing Address - State:TX
Mailing Address - Zip Code:75961-6488
Mailing Address - Country:US
Mailing Address - Phone:936-560-5668
Mailing Address - Fax:936-560-3928
Practice Address - Street 1:1401 S UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:NACOGDOCHES
Practice Address - State:TX
Practice Address - Zip Code:75961-6488
Practice Address - Country:US
Practice Address - Phone:936-560-5668
Practice Address - Fax:936-560-3928
Is Sole Proprietor?:No
Enumeration Date:2007-04-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL0657207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXG24255Medicare UPIN