MEDICARE: TRACIE DALENE UPDIKE M.D.

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	J4577	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1629070750
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TRACIE DALENE UPDIKE M.D.

Provider Business Mailing Address
First Line	:	2933 PARK PLAZA LN
Second Line	:
City	:	PORT ARTHUR
State	:	TX
Zip	:	77642-5516
Country	:	US
Telephone Number	:	409-983-1899
Fax Number	:	409-983-5225

Provider Business Practice Location Address
First Line	:	2933 PARK PLAZA LN
Second Line	:
City	:	PORT ARTHUR
State	:	TX
Zip	:	77642-5516
Country	:	US
Telephone Number	:	409-983-1899
Fax Number	:	409-983-5225

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

Provider Enumeration Date	:	06/01/2005
Last Update Date	:	07/12/2007

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