Provider Demographics
NPI:1396899282
Name:WILES, TRACEY JEANNETTE (DO)
Entity type:Individual
Prefix:
First Name:TRACEY
Middle Name:JEANNETTE
Last Name:WILES
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:PO BOX 1090
Mailing Address - Street 2:
Mailing Address - City:WINDSOR
Mailing Address - State:CT
Mailing Address - Zip Code:06095-6190
Mailing Address - Country:US
Mailing Address - Phone:203-709-5935
Mailing Address - Fax:203-709-5942
Practice Address - Street 1:1598 E MAIN ST
Practice Address - Street 2:
Practice Address - City:TORRINGTON
Practice Address - State:CT
Practice Address - Zip Code:06790-3519
Practice Address - Country:US
Practice Address - Phone:860-489-8444
Practice Address - Fax:860-496-8641
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2021-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000270207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT5002704Medicaid
CT110006789Medicare PIN
CT5002704Medicaid