Healthcare Provider Details

I. General information

NPI: 1548502628
Provider Name (Legal Business Name): ANTHONY PAUL TRACE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2013
Last Update Date: 12/15/2025
Certification Date: 12/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 KINGSLEY LN STE 305
NORFOLK VA
23505-4617
US

IV. Provider business mailing address

110 KINGSLEY LN STE 305
NORFOLK VA
23505-4617
US

V. Phone/Fax

Practice location:
  • Phone: 757-889-5422
  • Fax: 757-889-5450
Mailing address:
  • Phone: 757-889-5422
  • Fax: 757-889-5450

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number0101257244
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: