Provider Demographics
NPI:1831169838
Name:BURTON-LINDNER, TRACEY R (MD)
Entity type:Individual
Prefix:DR
First Name:TRACEY
Middle Name:R
Last Name:BURTON-LINDNER
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 1:1001 COLLEGE BLVD W STE C
Mailing Address - Street 2:
Mailing Address - City:NICEVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32578-1049
Mailing Address - Country:US
Mailing Address - Phone:850-678-9009
Mailing Address - Fax:
Practice Address - Street 1:1001 W COLLEGE BLVD
Practice Address - Street 2:SUITE C
Practice Address - City:NICEVILLE
Practice Address - State:FL
Practice Address - Zip Code:32578
Practice Address - Country:US
Practice Address - Phone:850-678-9009
Practice Address - Fax:850-678-9009
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-24
Last Update Date:2018-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0060775208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
25242OtherBLUE SHIELD
FL375291700Medicaid