Healthcare Provider Details

I. General information

NPI: 1053553495
Provider Name (Legal Business Name): NEIL A TRACY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2009
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3215 N. NORTH HILL ROAD
FAYETTEVILLE AR
72703-4424
US

IV. Provider business mailing address

PO BOX 550
LOWELL AR
72745-0550
US

V. Phone/Fax

Practice location:
  • Phone: 479-463-7102
  • Fax: 479-463-7864
Mailing address:
  • Phone: 479-463-6004
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberE-7197
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: