Healthcare Provider Details

I. General information

NPI: 1073968244
Provider Name (Legal Business Name): TRACEY L TAYLOR D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/25/2016
Last Update Date: 09/11/2020
Certification Date: 09/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3100 SAN PABLO AVE # 310
BERKELEY CA
94702-2498
US

IV. Provider business mailing address

1450 TREAT BLVD # 300
WALNUT CREEK CA
94597-2168
US

V. Phone/Fax

Practice location:
  • Phone: 510-985-5000
  • Fax:
Mailing address:
  • Phone: 925-952-2855
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number20A17010
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: