Provider Demographics
NPI:1952395535
Name:BLAND DUBOSE, TRACY D (MD)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:D
Last Name:BLAND DUBOSE
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:3495 PIEDMONT RD NE
Mailing Address - Street 2:NINE PIEDMONT CENTER
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30305-1717
Mailing Address - Country:US
Mailing Address - Phone:404-364-7000
Mailing Address - Fax:404-364-4732
Practice Address - Street 1:5440 HILLANDALE DR
Practice Address - Street 2:DEPARTMENT OF OB GYN
Practice Address - City:LITHONIA
Practice Address - State:GA
Practice Address - Zip Code:30058-4865
Practice Address - Country:US
Practice Address - Phone:770-322-2716
Practice Address - Fax:770-322-3244
Is Sole Proprietor?:No
Enumeration Date:2005-09-09
Last Update Date:2022-01-13
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Provider Licenses
StateLicense IDTaxonomies
GA052865207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA994626282AMedicaid
GA58-1397572OtherFEDERAL TAX ID#