Provider Demographics
NPI:1154398493
Name:TUCKER, GARY JACKSON JR (MD)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:JACKSON
Last Name:TUCKER
Suffix:JR
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 1:418 COLEGATE DR
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:OH
Mailing Address - Zip Code:45750-9549
Mailing Address - Country:US
Mailing Address - Phone:740-568-0412
Mailing Address - Fax:740-568-0413
Practice Address - Street 1:418 COLEGATE DR
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:OH
Practice Address - Zip Code:45750-9549
Practice Address - Country:US
Practice Address - Phone:740-568-0412
Practice Address - Fax:740-568-0413
Is Sole Proprietor?:No
Enumeration Date:2006-03-07
Last Update Date:2015-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV18392207Q00000X
OH35.098674207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0193633Medicaid
WV0054604000Medicaid
OHP01036081OtherMEDICARE RAILROAD
OH0193633Medicaid
OHH067721Medicare PIN
OHP01036081OtherMEDICARE RAILROAD
0813506Medicare ID - Type Unspecified