Provider Demographics
NPI:1346746062
Name:BOLOGNA-JILL, TRACI M (DPM)
Entity type:Individual
Prefix:DR
First Name:TRACI
Middle Name:M
Last Name:BOLOGNA-JILL
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 RANDALL SQ STE 408
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02904-7405
Mailing Address - Country:US
Mailing Address - Phone:401-453-2000
Mailing Address - Fax:401-253-2002
Practice Address - Street 1:1 RANDALL SQ STE 408
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02904-7405
Practice Address - Country:US
Practice Address - Phone:401-453-2000
Practice Address - Fax:401-253-2002
Is Sole Proprietor?:No
Enumeration Date:2018-04-02
Last Update Date:2022-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
RIDPM00367213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program