Healthcare Provider Details

I. General information

NPI: 1285669895
Provider Name (Legal Business Name): TRACY C BRITO M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2006
Last Update Date: 06/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3401 N PERRYVILLE RD
ROCKFORD IL
61114-8011
US

IV. Provider business mailing address

3401 N PERRYVILLE RD
ROCKFORD IL
61114-8011
US

V. Phone/Fax

Practice location:
  • Phone: 815-971-2000
  • Fax: 815-971-9447
Mailing address:
  • Phone: 815-971-2000
  • Fax: 815-971-9447

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036074111
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code202K00000X
TaxonomyPhlebology Physician
License Number036074111
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: