Basic Information
| Provider Information | |||||||||
| NPI: | 1033121892 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TRACY | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | P | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1530 PINE GROVE AVE | ||||||||
| Address2: | STE 7 | ||||||||
| City: | PORT HURON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48060 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8109850029 | ||||||||
| FaxNumber: | 8109850032 | ||||||||
| Practice Location | |||||||||
| Address1: | 1530 PINE GROVE AVE | ||||||||
| Address2: | STE 7 | ||||||||
| City: | PORT HURON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48060 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8109850029 | ||||||||
| FaxNumber: | 8109850032 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/12/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 066578 | MI | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 4094810 | 05 | MI | MEDICAID |