Provider Demographics
NPI:1215919550
Name:TRACY, KEVIN ABRAHAM (MD)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:ABRAHAM
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 1:9555 CEDAR RAIL WAY
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95624-6016
Mailing Address - Country:US
Mailing Address - Phone:916-714-7677
Mailing Address - Fax:
Practice Address - Street 1:2521 STOCKTON BLVD
Practice Address - Street 2:GLASSROCK BLDG. SUITE 4100
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95817-2207
Practice Address - Country:US
Practice Address - Phone:916-734-5846
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG55177208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G551770Medicaid
CAA52888Medicare UPIN