Provider Demographics
NPI:1154610640
Name:IRWIN, JOHN TUCKER
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:TUCKER
Last Name:IRWIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 STILLMEADOW RD SW
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30094-5703
Mailing Address - Country:US
Mailing Address - Phone:770-827-9526
Mailing Address - Fax:
Practice Address - Street 1:1200 STILLMEADOW RD SW
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30094-5703
Practice Address - Country:US
Practice Address - Phone:770-827-9526
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-05
Last Update Date:2024-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301105193207P00000X
OH35.124062207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine