1619226255 NPI number — DR. TIFFANY NICOLE TRACY MD

Table of content: DR. TIFFANY NICOLE TRACY MD (NPI 1619226255)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619226255 NPI number — DR. TIFFANY NICOLE TRACY MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TRACY
Provider First Name:
TIFFANY
Provider Middle Name:
NICOLE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1619226255
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/13/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11511 SHADOW CREEK PKWY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PEARLAND
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77584-7298
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
713-442-0000
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
17198 ST LUKES WAY
Provider Second Line Business Practice Location Address:
SUITE 540
Provider Business Practice Location Address City Name:
THE WOODLANDS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77384-8011
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
713-442-1900
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/29/2012

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207V00000X , with the licence number:  Q4864 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 353701101 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 353701103 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 353701102 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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