Provider Demographics
NPI:1053536268
Name:FUNK, TRACY (MD)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:FUNK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:TRACY
Other - Middle Name:LYNNE
Other - Last Name:MCGREGOR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:3303 SW BOND AVE # 16D
Mailing Address - Street 2:OHSU DEPARTMENT OF DERMATOLOGY
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-4501
Mailing Address - Country:US
Mailing Address - Phone:503-418-3376
Mailing Address - Fax:503-346-8106
Practice Address - Street 1:3303 SW BOND AVE # 16D
Practice Address - Street 2:OHSU DEPARTMENT OF DERMATOLOGY
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-4501
Practice Address - Country:US
Practice Address - Phone:503-418-3376
Practice Address - Fax:503-346-8106
Is Sole Proprietor?:No
Enumeration Date:2007-04-14
Last Update Date:2015-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO47554208000000X, 390200000X
OR173370207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO82253862Medicaid
COCOA101273Medicare PIN