Provider Demographics
NPI:1831146802
Name:DEBIASO, TRACY (MD)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:DEBIASO
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 1:230 LAUREL HEIGHTS DRIVE
Mailing Address - Street 2:
Mailing Address - City:BRIDGETON
Mailing Address - State:NJ
Mailing Address - Zip Code:08302-3634
Mailing Address - Country:US
Mailing Address - Phone:856-451-9595
Mailing Address - Fax:856-451-4130
Practice Address - Street 1:230 LAUREL HEIGHTS DRIVE
Practice Address - Street 2:
Practice Address - City:BRIDGETON
Practice Address - State:NJ
Practice Address - Zip Code:08302-3634
Practice Address - Country:US
Practice Address - Phone:856-451-9595
Practice Address - Fax:856-451-4130
Is Sole Proprietor?:No
Enumeration Date:2006-05-27
Last Update Date:2010-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA06258600207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
F16382OtherHEALTH NET
NJ6605907Medicaid
J3322OtherHORIZON
1469012002OtherCIGNA
784858L14Medicare ID - Type Unspecified
NJ6605907Medicaid