Healthcare Provider Details

I. General information

NPI: 1629140686
Provider Name (Legal Business Name): TRACY ANN CLARK M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2006
Last Update Date: 06/01/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2801 ATLANTIC AVE
LONG BEACH CA
90806-1701
US

IV. Provider business mailing address

PO BOX 1427
MONROVIA CA
91017-1427
US

V. Phone/Fax

Practice location:
  • Phone: 562-933-8743
  • Fax:
Mailing address:
  • Phone: 562-933-8743
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA90245
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: