Healthcare Provider Details

I. General information

NPI: 1700174000
Provider Name (Legal Business Name): TRACY CHAPMAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2011
Last Update Date: 01/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 N LAKEMONT AVE PEDIATRIC INPT CARE AT WINTER PARK
WINTER PARK FL
32792-3273
US

IV. Provider business mailing address

2501 N ORANGE AVE STE 446
ORLANDO FL
32804-4644
US

V. Phone/Fax

Practice location:
  • Phone: 407-303-2528
  • Fax: 407-303-2760
Mailing address:
  • Phone: 407-303-2528
  • Fax: 407-303-2760

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number5101019501
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberOS12891
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: