Provider Demographics
NPI:1962436030
Name:TRACY, MARK S (DPM)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:S
Last Name:TRACY
Suffix:
Gender:M
Credentials:DPM
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Mailing Address - Street 1:3028 CARING WAY
Mailing Address - Street 2:STE 9
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33952-5300
Mailing Address - Country:US
Mailing Address - Phone:941-627-6366
Mailing Address - Fax:941-627-6677
Practice Address - Street 1:3028 CARING WAY
Practice Address - Street 2:STE 9
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33952-5300
Practice Address - Country:US
Practice Address - Phone:941-627-6366
Practice Address - Fax:941-627-6677
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2010-07-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLPO1878213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE141AMedicare PIN
FL0686580001Medicare NSC
FL65044Medicare ID - Type Unspecified
T84350Medicare UPIN