Provider Demographics
NPI:1881778678
Name:RICO, TRACEY (MD)
Entity type:Individual
Prefix:DR
First Name:TRACEY
Middle Name:
Last Name:RICO
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 1:5482 WILSHIRE BLVD # 1630
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90036-4218
Mailing Address - Country:US
Mailing Address - Phone:917-310-1644
Mailing Address - Fax:
Practice Address - Street 1:272 LINCOLN PL
Practice Address - Street 2:SUITE D-3
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11238-5837
Practice Address - Country:US
Practice Address - Phone:718-857-0402
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2012-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY203203207PP0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PP0204XAllopathic & Osteopathic PhysiciansEmergency MedicinePediatric Emergency Medicine