Provider Demographics
NPI:1740351782
Name:THOMPSON, TRACI LYNN (MD)
Entity type:Individual
Prefix:
First Name:TRACI
Middle Name:LYNN
Last Name:THOMPSON
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 1:14714 TUDOR CHASE DR
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33626-3339
Mailing Address - Country:US
Mailing Address - Phone:410-493-3901
Mailing Address - Fax:
Practice Address - Street 1:904 E HENRY AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33604-7143
Practice Address - Country:US
Practice Address - Phone:813-501-7796
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-13
Last Update Date:2021-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME89582207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL272339500Medicaid
FLH86804Medicare UPIN