=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689637811
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ROBERT TRACER
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/10/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3131 KINGS HWY SUITE D7
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11234-2644
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-240-6385
-----------------------------------------------------
Fax | 718-240-6756
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1918 E 22ND ST
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11229-1527
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-336-8870
-----------------------------------------------------
Fax | 718-382-9423
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RG0100X
-----------------------------------------------------
Taxonomy Name | Gastroenterology Physician
-----------------------------------------------------
License Number | 147410
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------