Provider Demographics
NPI:1871593194
Name:TRACY DERMATOLOGY MEDICAL GROUP
Entity type:Organization
Organization Name:TRACY DERMATOLOGY MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:N
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:DIAKON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:209-836-2220
Mailing Address - Street 1:1470 BESSIE AVE
Mailing Address - Street 2:
Mailing Address - City:TRACY
Mailing Address - State:CA
Mailing Address - Zip Code:95376-3417
Mailing Address - Country:US
Mailing Address - Phone:209-836-2220
Mailing Address - Fax:209-836-0726
Practice Address - Street 1:1470 BESSIE AVE
Practice Address - Street 2:
Practice Address - City:TRACY
Practice Address - State:CA
Practice Address - Zip Code:95376-3417
Practice Address - Country:US
Practice Address - Phone:209-836-2220
Practice Address - Fax:209-836-0726
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A4430207N00000X
CAG49728207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00AX44430Medicaid
E08760Medicare UPIN
H09077Medicare UPIN
CA00AX44430Medicaid
00G491280Medicare ID - Type UnspecifiedDR BARNETT