Provider Demographics
NPI:1902456379
Name:TRACY ORTHOPEDICS AND SPORTS MEDICAL CENTER
Entity Type:Organization
Organization Name:TRACY ORTHOPEDICS AND SPORTS MEDICAL CENTER
Other - Org Name:TRACY ORTHOPEDICS AND SPORTS MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PREDIDENT
Authorized Official - Prefix:
Authorized Official - First Name:FRANK
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:DE MAYO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:209-835-4888
Mailing Address - Street 1:793 S TRACY BLVD STE 332
Mailing Address - Street 2:
Mailing Address - City:TRACY
Mailing Address - State:CA
Mailing Address - Zip Code:95376-4753
Mailing Address - Country:US
Mailing Address - Phone:209-835-4888
Mailing Address - Fax:209-835-6424
Practice Address - Street 1:530 W EATON AVE STE E
Practice Address - Street 2:
Practice Address - City:TRACY
Practice Address - State:CA
Practice Address - Zip Code:95376-3455
Practice Address - Country:US
Practice Address - Phone:209-835-4888
Practice Address - Fax:209-835-6424
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-17
Last Update Date:2023-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Multi-Specialty
No2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSportsGroup - Multi-Specialty
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Multi-Specialty