Provider Demographics
NPI:1366438384
Name:TRACY, WALLACE LEE (MD)
Entity type:Individual
Prefix:DR
First Name:WALLACE
Middle Name:LEE
Last Name:TRACY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1940 S WHITEHEAD DR
Mailing Address - Street 2:PO BOX 471
Mailing Address - City:DE WITT
Mailing Address - State:AR
Mailing Address - Zip Code:72042-2906
Mailing Address - Country:US
Mailing Address - Phone:870-946-4505
Mailing Address - Fax:870-946-2428
Practice Address - Street 1:1940 S WHITEHEAD DR
Practice Address - Street 2:
Practice Address - City:DE WITT
Practice Address - State:AR
Practice Address - Zip Code:72042-2906
Practice Address - Country:US
Practice Address - Phone:870-946-4505
Practice Address - Fax:870-946-2428
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-26
Last Update Date:2010-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC7340207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR114942001Medicaid
ARE02920Medicare UPIN
AR50594Medicare ID - Type Unspecified