Provider Demographics
NPI:1780777425
Name:GRIKSCHEIT, TRACY CANNON (MD)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:CANNON
Last Name:GRIKSCHEIT
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 1:6430 SUNSET BLVD.
Mailing Address - Street 2:SUITE 600
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90028-7900
Mailing Address - Country:US
Mailing Address - Phone:323-669-2337
Mailing Address - Fax:323-644-8491
Practice Address - Street 1:4650 SUNSET BLVD.
Practice Address - Street 2:MS# 100
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90027-6062
Practice Address - Country:US
Practice Address - Phone:323-669-2322
Practice Address - Fax:323-666-3466
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2019-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA967122086S0120X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric Surgery