Healthcare Provider Details

I. General information

NPI: 1083005474
Provider Name (Legal Business Name): ROBERT TRACY DO, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/06/2015
Last Update Date: 09/04/2024
Certification Date: 09/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3056 FLETCHER DR
LOS ANGELES CA
90065-2207
US

IV. Provider business mailing address

3056 FLETCHER DR
LOS ANGELES CA
90065-2207
US

V. Phone/Fax

Practice location:
  • Phone: 323-256-2231
  • Fax: 323-892-2571
Mailing address:
  • Phone: 323-256-2231
  • Fax: 323-892-2571

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: ROBERT A TRACY
Title or Position: OWNER
Credential: D.O.
Phone: 323-256-2231