Healthcare Provider Details

I. General information

NPI: 1720306558
Provider Name (Legal Business Name): TRACY WALLACE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2010
Last Update Date: 05/19/2021
Certification Date: 05/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1937 S BURNSIDE AVE
GONZALES LA
70737-4632
US

IV. Provider business mailing address

5959 S SHERWOOD FOREST BLVD
BATON ROUGE LA
70816-6038
US

V. Phone/Fax

Practice location:
  • Phone: 225-765-5500
  • Fax: 225-644-9286
Mailing address:
  • Phone: 225-765-5727
  • Fax: 225-765-9196

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number204717
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: