1902873151 NPI number — LAKEEYA K TUCKER DO

Table of content: LAKEEYA K TUCKER DO (NPI 1902873151)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902873151 NPI number — LAKEEYA K TUCKER DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TUCKER
Provider First Name:
LAKEEYA
Provider Middle Name:
K
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
DOTSON TUCKER
Provider Other First Name:
LAKEEYA
Provider Other Middle Name:
K
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
DO
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1902873151
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/18/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1560 TURF LANE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EAST LANSING
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48823-6392
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
517-484-3000
Provider Business Mailing Address Fax Number:
517-484-6358

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1560 TURF LANE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EAST LANSING
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48823-6392
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
517-484-3000
Provider Business Practice Location Address Fax Number:
517-484-6358
Provider Enumeration Date:
03/07/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207V00000X , with the licence number:  LT014020 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 4387080 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5330320 . This is a "BCBS/BCN PROVIDER #" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 0700261 . This is a "PHP PROVIDER #" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 0770041 . This is a "PHP FAMILY CARE PROVIDER" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1006153 . This is a "MCLAREN PROVIDER #" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: P00150117 . This is a "RR MEDICARE PROVIDER #" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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