Provider Demographics
NPI:1841269156
Name:TRACY, DEREK D (DC)
Entity type:Individual
Prefix:DR
First Name:DEREK
Middle Name:D
Last Name:TRACY
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:223 9TH ST
Mailing Address - Street 2:
Mailing Address - City:PORT ST. JOE
Mailing Address - State:FL
Mailing Address - Zip Code:32456-1923
Mailing Address - Country:US
Mailing Address - Phone:850-227-7222
Mailing Address - Fax:
Practice Address - Street 1:223 9TH ST
Practice Address - Street 2:
Practice Address - City:PORT ST JOE
Practice Address - State:FL
Practice Address - Zip Code:32456-1923
Practice Address - Country:US
Practice Address - Phone:850-227-7222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-17
Last Update Date:2016-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH 10351111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLGO776ZOtherPROVIDER TRANSACTION ACESS NUMBER