Provider Demographics
NPI:1205929270
Name:SKOLNICK, TRACY MARLA (DO)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:MARLA
Last Name:SKOLNICK
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:151 RAINBOW VALLEY LN
Mailing Address - Street 2:
Mailing Address - City:NEWCASTLE
Mailing Address - State:CA
Mailing Address - Zip Code:95658-9421
Mailing Address - Country:US
Mailing Address - Phone:916-276-1389
Mailing Address - Fax:
Practice Address - Street 1:151 RAINBOW VALLEY LN
Practice Address - Street 2:
Practice Address - City:NEWCASTLE
Practice Address - State:CA
Practice Address - Zip Code:95658-9421
Practice Address - Country:US
Practice Address - Phone:916-276-1389
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2014-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A9731207RH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAH05437Medicare UPIN
PA054872Medicare ID - Type UnspecifiedPROVIDER IDENTIFICATION