Individual
TRACEY WAY CHILDERS
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
D.O.
Contact information
Practice address
1203 E ROSS BYP, SUITE A, TAHLEQUAH, OK 74464-4188
(918) 453-1234
(918) 453-9107
Mailing address
1203 E ROSS BYP, SUITE A, TAHLEQUAH, OK 74464-4188
(918) 453-1234
(918) 453-9107
Taxonomy
Speciality
Code
Description
License number
State
207YX0905X
Otolaryngology/Facial Plastic Surgery Physician
Primary
3296
OK
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
100257460A
—
OK
05
—
200000030A
—
OK
01
—
DA5295
RAILROAD MEDICARE GROUP NUMBER
OK
01
—
P00027981
RAILROAD MEDICARE PIN NUMBER
OK
Enumeration date
03/24/2006
Last updated
05/28/2024
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