Provider Demographics
NPI:1063415362
Name:TUCKER, SCOTT L (MD)
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:L
Last Name:TUCKER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1345 WESTGATE CENTER DR STE A
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-3041
Mailing Address - Country:US
Mailing Address - Phone:336-768-8483
Mailing Address - Fax:336-768-1195
Practice Address - Street 1:1345A WESTGATE CENTER DR
Practice Address - Street 2:
Practice Address - City:WINSTON-SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-2934
Practice Address - Country:US
Practice Address - Phone:336-768-8483
Practice Address - Fax:336-768-1195
Is Sole Proprietor?:No
Enumeration Date:2005-05-31
Last Update Date:2009-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200001832740208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2086S0122XOtherTAXONOMY
NC2325790OtherMEDICARE GROUP
NC8983956Medicaid
NC83956OtherBCBSNC
NC2325790OtherMEDICARE GROUP
NC83956OtherBCBSNC