1194790352 NPI number — DR. DAVID N TUCKER O.D.

Table of content: DR. DAVID N TUCKER O.D. (NPI 1194790352)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194790352 NPI number — DR. DAVID N TUCKER O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TUCKER
Provider First Name:
DAVID
Provider Middle Name:
N
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
O.D.
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:
1194790352
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 7009
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PADUCAH
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
42002-7009
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
270-443-9955
Provider Business Mailing Address Fax Number:
270-442-1469

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1748 BROADWAY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PADUCAH
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42001-2706
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-443-9955
Provider Business Practice Location Address Fax Number:
270-442-1469
Provider Enumeration Date:
02/21/2006

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: 152W00000X , with the licence number:  937DT , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 174400000X , with the licence number: 937DT , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 5789371 . This is a "AETNA" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 000000050469 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: Y54702 . This is a "BLUEGRASS FAMILY HEALTH" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 390982 . This is a "HEALTHLINK" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 77009371 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




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