Provider Demographics
NPI:1265189153
Name:GODFREY, TRACY S (MD)
Entity type:Individual
Prefix:DR
First Name:TRACY
Middle Name:S
Last Name:GODFREY
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 1:421 WHITNEY AVE APT 4
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06511-2342
Mailing Address - Country:US
Mailing Address - Phone:203-215-5074
Mailing Address - Fax:
Practice Address - Street 1:421 WHITNEY AVE APT 4
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06511-2342
Practice Address - Country:US
Practice Address - Phone:203-215-5074
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-09
Last Update Date:2022-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR16088-I390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program