Provider Demographics
NPI:1144260126
Name:MENDEZ, TRACEYAN R (MD)
Entity type:Individual
Prefix:
First Name:TRACEYAN
Middle Name:R
Last Name:MENDEZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:TRACEYAN
Other - Middle Name:R
Other - Last Name:REID
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 783311
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19178-3311
Mailing Address - Country:US
Mailing Address - Phone:484-884-4500
Mailing Address - Fax:484-884-0699
Practice Address - Street 1:750 ROUTE 739
Practice Address - Street 2:
Practice Address - City:LORDS VALLEY
Practice Address - State:PA
Practice Address - Zip Code:18428-6058
Practice Address - Country:US
Practice Address - Phone:570-775-7100
Practice Address - Fax:570-775-0950
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2023-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA057831207Q00000X
PAMD453022207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA718892461AMedicaid
GA000632376GMedicaid
GA111830OtherUGS-SWAINSBORO
GA111889OtherUGS-SOPERTON
GA000632376AMedicaid
GA111887OtherUGS-REIDSVILLE
GA111887OtherUGS-REIDSVILLE
GA08CBBQFMedicare ID - Type Unspecified