Provider Demographics
NPI:1831157858
Name:IVEY, TRACI L (MD)
Entity type:Individual
Prefix:DR
First Name:TRACI
Middle Name:L
Last Name:IVEY
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 1:2104 S 54TH ST STE 4
Mailing Address - Street 2:
Mailing Address - City:ROGERS
Mailing Address - State:AR
Mailing Address - Zip Code:72758-8194
Mailing Address - Country:US
Mailing Address - Phone:479-268-4504
Mailing Address - Fax:479-222-0061
Practice Address - Street 1:2905 S WALTON BLVD
Practice Address - Street 2:SUITE 17
Practice Address - City:BENTONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72712-6730
Practice Address - Country:US
Practice Address - Phone:479-657-6501
Practice Address - Fax:479-657-6375
Is Sole Proprietor?:No
Enumeration Date:2006-05-01
Last Update Date:2024-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARR4023207QH0002X, 2083P0011X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QH0002XAllopathic & Osteopathic PhysiciansFamily MedicineHospice and Palliative Medicine
No2083P0011XAllopathic & Osteopathic PhysiciansPreventive MedicineUndersea and Hyperbaric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR117573001Medicaid
AR52620Medicare PIN
ARE44252Medicare UPIN