Provider Demographics
NPI:1154596120
Name:DONALD TUCKER PLLC
Entity type:Organization
Organization Name:DONALD TUCKER PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:V
Authorized Official - Last Name:TUCKER
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:931-454-0489
Mailing Address - Street 1:100 WILLIAM NORTHERN BLVD
Mailing Address - Street 2:
Mailing Address - City:TULLAHOMA
Mailing Address - State:TN
Mailing Address - Zip Code:37388
Mailing Address - Country:US
Mailing Address - Phone:931-454-0489
Mailing Address - Fax:931-454-2348
Practice Address - Street 1:100 WILLIAM NORTHERN BLVD
Practice Address - Street 2:
Practice Address - City:TULLAHOMA
Practice Address - State:TN
Practice Address - Zip Code:37388-4754
Practice Address - Country:US
Practice Address - Phone:931-454-0489
Practice Address - Fax:931-454-2348
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-29
Last Update Date:2008-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD024197207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1505159Medicaid
TN4185013OtherBCBS
TN30733002Medicare PIN