Provider Demographics
NPI:1801869961
Name:TRACE, ROBERT JOHN JR (MD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:JOHN
Last Name:TRACE
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:ROBERT
Other - Middle Name:JOHN
Other - Last Name:TRACE
Other - Suffix:JR
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:121 E ANTIETAM ST
Mailing Address - Street 2:
Mailing Address - City:HAGERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21740
Mailing Address - Country:US
Mailing Address - Phone:301-739-2560
Mailing Address - Fax:301-739-0266
Practice Address - Street 1:121 E ANTIETAM ST
Practice Address - Street 2:
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21740
Practice Address - Country:US
Practice Address - Phone:301-739-2560
Practice Address - Fax:301-739-0266
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-09
Last Update Date:2010-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD22012207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDW0180001OtherBLUE CROSS BLUE SHIELD
MD964111400Medicaid
MD964111400Medicaid
D73872Medicare UPIN