Provider Demographics
NPI:1992897714
Name:MIDDLEBROOKS, TRACY WILLIAMS JR (MD)
Entity type:Individual
Prefix:DR
First Name:TRACY
Middle Name:WILLIAMS
Last Name:MIDDLEBROOKS
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1505 WINTER ST
Mailing Address - Street 2:SUITE D
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30904
Mailing Address - Country:US
Mailing Address - Phone:706-667-0070
Mailing Address - Fax:706-667-0073
Practice Address - Street 1:2315 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30904-6272
Practice Address - Country:US
Practice Address - Phone:706-667-0070
Practice Address - Fax:706-667-0073
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-29
Last Update Date:2019-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA24986208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00266775AMedicaid