Healthcare Provider Details

I. General information

NPI: 1255674818
Provider Name (Legal Business Name): JOSEPHINE TRACY M.D, MPH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JOSEPHINE VINCENT M.D, MPH

II. Dates (important events)

Enumeration Date: 04/02/2013
Last Update Date: 06/21/2021
Certification Date: 06/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8008 WESTPARK DR
MC LEAN VA
22102-3109
US

IV. Provider business mailing address

9500 CLARKS CROSSING RD
VIENNA VA
22182-1926
US

V. Phone/Fax

Practice location:
  • Phone: 860-884-5508
  • Fax:
Mailing address:
  • Phone: 860-884-5508
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number125065504
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number0101267049
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: