Provider Demographics
NPI:1104090265
Name:FRITZ, TRACI RENAE (MD)
Entity type:Individual
Prefix:DR
First Name:TRACI
Middle Name:RENAE
Last Name:FRITZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6100 W STATE ST APT 404
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53213-2994
Mailing Address - Country:US
Mailing Address - Phone:254-485-9570
Mailing Address - Fax:414-475-7706
Practice Address - Street 1:6100 W STATE ST APT 404
Practice Address - Street 2:
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53213-2994
Practice Address - Country:US
Practice Address - Phone:254-485-9570
Practice Address - Fax:414-475-7706
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-18
Last Update Date:2019-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI64874208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1104090265Medicaid
WI1508830076Medicaid