1023169539 NPI number — JOHN O TUCKER D.C.

Table of content: (NPI 1174855928)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023169539 NPI number — JOHN O TUCKER D.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TUCKER
Provider First Name:
JOHN
Provider Middle Name:
O
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
D.C.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1023169539
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/19/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
202 ALLAMANDA DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAKELAND
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33803-2928
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
863-682-4182
Provider Business Mailing Address Fax Number:
863-682-7319

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
202 ALLAMANDA DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKELAND
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33803-2928
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
863-682-4182
Provider Business Practice Location Address Fax Number:
863-682-7319
Provider Enumeration Date:
01/13/2007

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: 111N00000X , with the licence number:  CH1520 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 350053678 . This is a "RAIL ROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 4407759 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 89514 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 0507164-00 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 45163 . This is a "BCBS HEALTH OPTIONS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 109435 . This is a "AMERIGROUP" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 189493 . This is a "STAYWELL" identifier . This identifiers is of the category "OTHER".
  • Identifier: 272544 . This is a "AVMED" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 189493 . This is a "WELLCARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 012144300 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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