Provider Demographics
NPI:1841277514
Name:DAVISON TRACY, BRANDON SCOTT (MD)
Entity type:Individual
Prefix:
First Name:BRANDON
Middle Name:SCOTT
Last Name:DAVISON TRACY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:BRANDON
Other - Middle Name:SCOTT
Other - Last Name:DAVISON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2975 ROSLYN ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80238-3326
Mailing Address - Country:US
Mailing Address - Phone:303-399-7900
Mailing Address - Fax:303-399-7999
Practice Address - Street 1:2975 ROSLYN ST
Practice Address - Street 2:SUITE 100
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80238-3326
Practice Address - Country:US
Practice Address - Phone:303-399-7900
Practice Address - Fax:303-399-7999
Is Sole Proprietor?:No
Enumeration Date:2005-12-23
Last Update Date:2007-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO39563208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO24006254Medicaid
COH64733Medicare UPIN
470228Medicare ID - Type Unspecified