Provider Demographics
NPI:1215460118
Name:TRACY, JONATHAN (MD)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:
Last Name:TRACY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:585 N 500 W
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84601-1548
Mailing Address - Country:US
Mailing Address - Phone:801-374-1801
Mailing Address - Fax:801-216-8357
Practice Address - Street 1:819 E MARKET PLACE DR 3RD FLOOR
Practice Address - Street 2:
Practice Address - City:SPANISH FORK
Practice Address - State:UT
Practice Address - Zip Code:84660-8466
Practice Address - Country:US
Practice Address - Phone:801-374-1801
Practice Address - Fax:801-216-8357
Is Sole Proprietor?:No
Enumeration Date:2017-04-06
Last Update Date:2021-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12227482207V00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology