MEDICARE: DR. TRACY THUY PHAN DO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	94295	GA
2	207Q00000X	Family Medicine Physician	34.017107	OH

General Provider Information

NPI Number	:	1619592987
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TRACY THUY PHAN DO

Provider Business Mailing Address
First Line	:	1 PRESTIGE PL STE 550
Second Line	:
City	:	MIAMISBURG
State	:	OH
Zip	:	45342-6115
Country	:	US
Telephone Number	:	937-762-1310
Fax Number	:	937-522-8068

Provider Business Practice Location Address
First Line	:	100 KETTERING WAY STE 100
Second Line	:
City	:	FRANKLIN
State	:	OH
Zip	:	45005-1155
Country	:	US
Telephone Number	:	937-746-8357
Fax Number	:	937-522-7079

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/12/2020
Last Update Date	:	09/13/2024

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Directions to “ DR. TRACY THUY PHAN DO” Practice Location

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