Healthcare Provider Details

I. General information

NPI: 1346432614
Provider Name (Legal Business Name): TRACY LEIGH CORDRAY M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/10/2007
Last Update Date: 10/13/2022
Certification Date: 10/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2093 HENRY TECKLENBURG DR STE 340
CHARLESTON SC
29414-5741
US

IV. Provider business mailing address

2093 HENRY TECKLENBURG DR STE 340
CHARLESTON SC
29414-5741
US

V. Phone/Fax

Practice location:
  • Phone: 843-718-2334
  • Fax: 843-277-2067
Mailing address:
  • Phone: 843-718-2334
  • Fax: 843-277-2067

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License NumberA79618
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number22185
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: