Healthcare Provider Details

I. General information

NPI: 1437122744
Provider Name (Legal Business Name): TRACY C ORTON DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/08/2006
Last Update Date: 10/20/2020
Certification Date: 10/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3100 N WELLNESS DR
HOLLAND MI
49424-8122
US

IV. Provider business mailing address

3100 N WELLNESS DR
HOLLAND MI
49424-8122
US

V. Phone/Fax

Practice location:
  • Phone: 616-994-2770
  • Fax: 616-920-6533
Mailing address:
  • Phone: 616-994-2770
  • Fax: 616-920-6533

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207KA0200X
TaxonomyAllergy Physician
License Number116144
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code207YX0007X
TaxonomyPlastic Surgery within the Head & Neck (Otolaryngology) Physician
License Number116144
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code207YX0007X
TaxonomyPlastic Surgery within the Head & Neck (Otolaryngology) Physician
License Number5101017139
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: