Provider Demographics
NPI:1902099716
Name:RICHARDSON, TRACEY (MD)
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 PROFESSIONAL DR
Mailing Address - Street 2:
Mailing Address - City:SNOW HILL
Mailing Address - State:NC
Mailing Address - Zip Code:28580-1332
Mailing Address - Country:US
Mailing Address - Phone:252-747-8162
Mailing Address - Fax:252-747-8163
Practice Address - Street 1:261 BELVOIR HWY
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27834-8193
Practice Address - Country:US
Practice Address - Phone:252-695-6352
Practice Address - Fax:252-695-6359
Is Sole Proprietor?:No
Enumeration Date:2007-08-24
Last Update Date:2014-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME100735207Q00000X
NC2013-00205207Q00000X
HIMD15845207Q00000X
FLTRN9975390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5922865Medicaid