Healthcare Provider Details

I. General information

NPI: 1477506251
Provider Name (Legal Business Name): JERRY J TRACY III MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2006
Last Update Date: 05/18/2022
Certification Date: 05/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

308 S HARBOR CITY BLVD STE A
MELBOURNE FL
32901-1500
US

IV. Provider business mailing address

11350 MCCORMICK RD STE 501
HUNT VALLEY MD
21031-1002
US

V. Phone/Fax

Practice location:
  • Phone: 321-733-0064
  • Fax:
Mailing address:
  • Phone: 703-914-8000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License NumberME154017
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number35064726
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: