Provider Demographics
NPI:1922502772
Name:BOURGEOIS, TRACI (MD)
Entity type:Individual
Prefix:
First Name:TRACI
Middle Name:
Last Name:BOURGEOIS
Suffix:
Gender:F
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:PO BOX 95590
Mailing Address - Street 2:
Mailing Address - City:SOUTH JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84095-0590
Mailing Address - Country:US
Mailing Address - Phone:448-227-4600
Mailing Address - Fax:448-227-9669
Practice Address - Street 1:1118 GULF BREEZE PKWY STE 100A
Practice Address - Street 2:
Practice Address - City:GULF BREEZE
Practice Address - State:FL
Practice Address - Zip Code:32561-7801
Practice Address - Country:US
Practice Address - Phone:850-908-2315
Practice Address - Fax:850-908-2307
Is Sole Proprietor?:No
Enumeration Date:2018-03-19
Last Update Date:2025-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA326107207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL125233800Medicaid
LA2465104Medicaid