Provider Demographics
NPI:1053371021
Name:CHILDERS, TRACEY WAY (DO)
Entity type:Individual
Prefix:
First Name:TRACEY
Middle Name:WAY
Last Name:CHILDERS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1203 E ROSS BYP
Mailing Address - Street 2:SUITE A
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74464-4188
Mailing Address - Country:US
Mailing Address - Phone:918-453-1234
Mailing Address - Fax:918-453-9107
Practice Address - Street 1:1203 E ROSS BYP
Practice Address - Street 2:SUITE A
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-4188
Practice Address - Country:US
Practice Address - Phone:918-453-1234
Practice Address - Fax:918-453-9107
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-24
Last Update Date:2024-05-28
Deactivation Date:2024-05-02
Deactivation Code:
Reactivation Date:2024-05-28
Provider Licenses
StateLicense IDTaxonomies
OK3296207YX0905X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YX0905XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngology/Facial Plastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKDA5295OtherRAILROAD MEDICARE GROUP NUMBER
OKP00027981OtherRAILROAD MEDICARE PIN NUMBER
OK200000030AMedicaid
OK100257460AMedicaid
OK100257460AMedicaid
OKDA5295OtherRAILROAD MEDICARE GROUP NUMBER
OKP00027981OtherRAILROAD MEDICARE PIN NUMBER