Provider Demographics
NPI:1912065285
Name:HATA, TRACIE F (MD)
Entity Type:Individual
Prefix:DR
First Name:TRACIE
Middle Name:F
Last Name:HATA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:2101 EAST JEFFERSON STREET
Mailing Address - Street 2:ATTN THERESA BROOKS PPQA MEDICARE COMPLIANCE UNIT 6 W
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20852-4908
Mailing Address - Country:US
Mailing Address - Phone:301-816-6660
Mailing Address - Fax:301-816-6308
Practice Address - Street 1:590 FARRINGTON HWY
Practice Address - Street 2:UNIT 526A
Practice Address - City:KAPOLEI
Practice Address - State:HI
Practice Address - Zip Code:96707-2009
Practice Address - Country:US
Practice Address - Phone:808-674-2930
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2012-10-31
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0101238475207Q00000X
CO38167207Q00000X
HI16197207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
H17659Medicare UPIN
018303K92Medicare ID - Type Unspecified