Provider Demographics
NPI:1902878408
Name:DODIG, TRACIE FARRELL (MD)
Entity Type:Individual
Prefix:
First Name:TRACIE
Middle Name:FARRELL
Last Name:DODIG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:TRACIE
Other - Middle Name:ANNE
Other - Last Name:FARRELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:14001 RIDGEDALE DR
Mailing Address - Street 2:#100
Mailing Address - City:MINNETONKA
Mailing Address - State:MN
Mailing Address - Zip Code:55305-1781
Mailing Address - Country:US
Mailing Address - Phone:952-473-0211
Mailing Address - Fax:952-473-7908
Practice Address - Street 1:14001 RIDGEDALE DR
Practice Address - Street 2:#100
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55305-1781
Practice Address - Country:US
Practice Address - Phone:952-473-0211
Practice Address - Fax:952-473-7908
Is Sole Proprietor?:No
Enumeration Date:2006-02-07
Last Update Date:2018-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN43498208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN087214800Medicaid