Provider Demographics
NPI:1437546306
Name:KIM, TRACEY (MD)
Entity type:Individual
Prefix:
First Name:TRACEY
Middle Name:
Last Name:KIM
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:665 WINTER ST SE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-3934
Mailing Address - Country:US
Mailing Address - Phone:818-521-2237
Mailing Address - Fax:
Practice Address - Street 1:665 WINTER ST SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-3934
Practice Address - Country:US
Practice Address - Phone:503-561-2448
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-18
Last Update Date:2025-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR223280208600000X, 2086S0102X, 2086S0127X
CO00690062086S0127X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care