1982620803 NPI number — TRACY LEIGH MARTIN M.D.

Table of content: TRACY LEIGH MARTIN M.D. (NPI 1982620803)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1982620803 NPI number — TRACY LEIGH MARTIN M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MARTIN
Provider First Name:
TRACY
Provider Middle Name:
LEIGH
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1982620803
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/10/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4033 TAMPA RD
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
OLDSMAR
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34677-3224
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
813-854-2003
Provider Business Mailing Address Fax Number:
813-855-2367

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5621 SKYTOP DRIVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LITHIA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33547-4165
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
813-571-6800
Provider Business Practice Location Address Fax Number:
813-654-9939
Provider Enumeration Date:
07/14/2006

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: 208000000X , with the licence number:  ME 75315 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2546388-00 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 254638800 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com