Provider Demographics
NPI:1336584523
Name:TRACEY, VIRGINIA ALLDREDGE (MD)
Entity Type:Individual
Prefix:DR
First Name:VIRGINIA
Middle Name:ALLDREDGE
Last Name:TRACEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:VIRGINIA
Other - Middle Name:DUNN
Other - Last Name:ALLDREDGE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:5824 WIDEWATERS PKWY STE 4
Mailing Address - Street 2:
Mailing Address - City:EAST SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13057-3072
Mailing Address - Country:US
Mailing Address - Phone:315-500-7546
Mailing Address - Fax:315-378-4210
Practice Address - Street 1:5824 WIDEWATERS PKWY STE 4
Practice Address - Street 2:
Practice Address - City:EAST SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13057-3072
Practice Address - Country:US
Practice Address - Phone:315-500-7546
Practice Address - Fax:315-378-4210
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-01
Last Update Date:2020-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY295881207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY295881OtherNYS LICENSE