Healthcare Provider Details

I. General information

NPI: 1902456379
Provider Name (Legal Business Name): TRACY ORTHOPEDICS AND SPORTS MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/17/2019
Last Update Date: 04/21/2023
Certification Date: 04/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

530 W EATON AVE STE E
TRACY CA
95376-3455
US

IV. Provider business mailing address

793 S TRACY BLVD STE 332
TRACY CA
95376-4753
US

V. Phone/Fax

Practice location:
  • Phone: 209-835-4888
  • Fax: 209-835-6424
Mailing address:
  • Phone: 209-835-4888
  • Fax: 209-835-6424

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: FRANK MICHAEL DE MAYO
Title or Position: PREDIDENT
Credential: MD
Phone: 209-835-4888