Provider Demographics
NPI:1306075759
Name:TUCKER, TIFFANY DIAN (OD)
Entity type:Individual
Prefix:MISS
First Name:TIFFANY
Middle Name:DIAN
Last Name:TUCKER
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7705 BLANDING BLVD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32244-5113
Mailing Address - Country:US
Mailing Address - Phone:904-923-2486
Mailing Address - Fax:
Practice Address - Street 1:7705 BLANDING BLVD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32244-5113
Practice Address - Country:US
Practice Address - Phone:904-923-2486
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-07
Last Update Date:2011-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618001871152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA293430601AMedicaid
FL0024606-00Medicaid
GA293430601AMedicaid