Provider Demographics
NPI:1124236054
Name:JECK, TRACY A (MD)
Entity type:Individual
Prefix:DR
First Name:TRACY
Middle Name:A
Last Name:JECK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:TRACY
Other - Middle Name:A
Other - Last Name:THALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:5150 E. GLENN ST.
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85712-1337
Mailing Address - Country:US
Mailing Address - Phone:520-795-7729
Mailing Address - Fax:520-795-4177
Practice Address - Street 1:5150 E. GLENN ST.
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85712-1337
Practice Address - Country:US
Practice Address - Phone:520-795-7729
Practice Address - Fax:520-795-4177
Is Sole Proprietor?:No
Enumeration Date:2007-05-21
Last Update Date:2020-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ37422207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ252688Medicaid
AZP00413317OtherRAILROAD MEDICARE
AZP00413317OtherRAILROAD MEDICARE
AZZ122849Medicare PIN