Basic Information
| Provider Information | |||||||||
| NPI: | 1952395535 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLAND DUBOSE | ||||||||
| FirstName: | TRACY | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3495 PIEDMONT RD NE | ||||||||
| Address2: | NINE PIEDMONT CENTER | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303051717 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4043647000 | ||||||||
| FaxNumber: | 4043644732 | ||||||||
| Practice Location | |||||||||
| Address1: | 5440 HILLANDALE DR | ||||||||
| Address2: | DEPARTMENT OF OB GYN | ||||||||
| City: | LITHONIA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300584865 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7703222716 | ||||||||
| FaxNumber: | 7703223244 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/09/2005 | ||||||||
| LastUpdateDate: | 01/13/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 052865 | GA | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 994626282A | 05 | GA | MEDICAID | 58-1397572 | 01 | GA | FEDERAL TAX ID# | OTHER |