Provider Demographics
NPI:1861515447
Name:TUCKER, CONSTANTINA C (DO)
Entity type:Individual
Prefix:
First Name:CONSTANTINA
Middle Name:C
Last Name:TUCKER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 WEST LINCOLN HWY
Mailing Address - Street 2:
Mailing Address - City:SCHERERVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46375-1554
Mailing Address - Country:US
Mailing Address - Phone:219-311-3311
Mailing Address - Fax:
Practice Address - Street 1:505 WEST LINCOLN HWY
Practice Address - Street 2:
Practice Address - City:SCHERERVILLE
Practice Address - State:IN
Practice Address - Zip Code:46375-1554
Practice Address - Country:US
Practice Address - Phone:219-311-3311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-09
Last Update Date:2019-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101016610207Q00000X
IN02004498A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036121455OtherSTATE LICENSE