Healthcare Provider Details

I. General information

NPI: 1043202203
Provider Name (Legal Business Name): MARK E TRACY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2005
Last Update Date: 08/22/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 E ROLLINS ST
ORLANDO FL
32803-1248
US

IV. Provider business mailing address

2718 N ORANGE AVE SUITE C
ORLANDO FL
32804-7611
US

V. Phone/Fax

Practice location:
  • Phone: 407-303-2578
  • Fax:
Mailing address:
  • Phone: 407-303-2578
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number036-109303
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberME113742
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: