Healthcare Provider Details

I. General information

NPI: 1053536268
Provider Name (Legal Business Name): TRACY FUNK MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TRACY LYNNE MCGREGOR M.D.

II. Dates (important events)

Enumeration Date: 04/14/2007
Last Update Date: 06/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3303 SW BOND AVE # 16D OHSU DEPARTMENT OF DERMATOLOGY
PORTLAND OR
97239-4501
US

IV. Provider business mailing address

3303 SW BOND AVE # 16D OHSU DEPARTMENT OF DERMATOLOGY
PORTLAND OR
97239-4501
US

V. Phone/Fax

Practice location:
  • Phone: 503-418-3376
  • Fax: 503-346-8106
Mailing address:
  • Phone: 503-418-3376
  • Fax: 503-346-8106

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number47554
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number47554
License Number StateCO
# 3
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number173370
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: