Healthcare Provider Details

I. General information

NPI: 1730110099
Provider Name (Legal Business Name): DONALD TRACY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 LONGWOOD AVE
BOSTON MA
02115-5724
US

IV. Provider business mailing address

14 ORDWAY RD
WELLESLEY MA
02481-6709
US

V. Phone/Fax

Practice location:
  • Phone: 617-355-8382
  • Fax:
Mailing address:
  • Phone: 614-355-6936
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085P0229X
TaxonomyPediatric Radiology Physician
License Number75774
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: