Provider Demographics
NPI:1316472657
Name:KIM, TRACEY (DO)
Entity type:Individual
Prefix:DR
First Name:TRACEY
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PSC 819 BOX 18
Mailing Address - Street 2:
Mailing Address - City:FPO
Mailing Address - State:AE
Mailing Address - Zip Code:09645-0001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:APARTADO DE CORREOS 33
Practice Address - Street 2:HOSPITAL AMERICANO, BASE NAVAL DE ROTA
Practice Address - City:ROTA
Practice Address - State:CADIZ
Practice Address - Zip Code:11530
Practice Address - Country:ES
Practice Address - Phone:000-000-0000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-24
Last Update Date:2022-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A170702083A0100X, 208D00000X
171000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083A0100XAllopathic & Osteopathic PhysiciansPreventive MedicineAerospace Medicine
No171000000XOther Service ProvidersMilitary Health Care Provider
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAD0000Medicare UPIN