Provider Demographics
NPI:1558350090
Name:TRUCHELUT, TRACY A (MD)
Entity type:Individual
Prefix:DR
First Name:TRACY
Middle Name:A
Last Name:TRUCHELUT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:TRACY
Other - Middle Name:A
Other - Last Name:WHITE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1925 MIZELL AVE
Mailing Address - Street 2:SUITE 302
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32792-4106
Mailing Address - Country:US
Mailing Address - Phone:407-629-6646
Mailing Address - Fax:407-740-5089
Practice Address - Street 1:1925 MIZELL AVE
Practice Address - Street 2:SUITE 302
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32792-4106
Practice Address - Country:US
Practice Address - Phone:407-629-6646
Practice Address - Fax:407-740-5089
Is Sole Proprietor?:No
Enumeration Date:2005-10-18
Last Update Date:2012-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME47684174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL47799OtherBCBS INDIVIDUAL ID #
FLD55185Medicare UPIN
FL98773Medicare ID - Type UnspecifiedGROUP ID #