1083662373 NPI number — DR. TUCKER D JOHNSON PHD

Table of content: DR. TUCKER D JOHNSON PHD (NPI 1083662373)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083662373 NPI number — DR. TUCKER D JOHNSON PHD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JOHNSON
Provider First Name:
TUCKER
Provider Middle Name:
D
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PHD
Provider Gender Code:
F

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:
1083662373
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/12/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
122 COVINGTON ST
Provider Second Line Business Mailing Address:
PO BOX 147
Provider Business Mailing Address City Name:
STANTON
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
38069-4428
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
731-548-6562
Provider Business Mailing Address Fax Number:
731-548-6563

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2014 EXETER RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GERMANTOWN
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
38138-3945
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
901-624-4600
Provider Business Practice Location Address Fax Number:
901-757-1485
Provider Enumeration Date:
05/05/2006

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: 103TC0700X , with the licence number:  P0000002427 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: P00329380 . This is a "MEDICARE RAILROAD" identifier . This identifiers is of the category "OTHER".