Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 208100000X | Physical Medicine & Rehabilitation Doctor | 036-109303 | IL |
Y | 208100000X | Physical Medicine & Rehabilitation Doctor | ME113742 | FL |
NPI | 1043202203 |
---|---|
Provider Name | Dr. Mark E Tracy |
First Address | Orlando, FL 32804-7611 |
Second Address | Orlando, FL 32803-1248 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 15/08/2005 |
Last Update Date | 22/08/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
036-109303-1 | (05) | IL |
I12489 | (02) | IL |