Provider Demographics
NPI:1174591820
Name:TCHUISSE, LUCIEN-MAXIMIN YANOU (MD)
Entity type:Individual
Prefix:
First Name:LUCIEN-MAXIMIN
Middle Name:YANOU
Last Name:TCHUISSE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7000 OLD WOLF BAY RD
Mailing Address - Street 2:
Mailing Address - City:PALATKA
Mailing Address - State:FL
Mailing Address - Zip Code:32177-6816
Mailing Address - Country:US
Mailing Address - Phone:386-325-5699
Mailing Address - Fax:386-325-5644
Practice Address - Street 1:7000 OLD WOLF BAY RD
Practice Address - Street 2:
Practice Address - City:PALATKA
Practice Address - State:FL
Practice Address - Zip Code:32177-6816
Practice Address - Country:US
Practice Address - Phone:386-325-5699
Practice Address - Fax:386-325-5644
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-09
Last Update Date:2022-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME85684207V00000X, 261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL264937300Medicaid
FL68-3815OtherMEDICARE PTAN
FL68-3815OtherMEDICARE PTAN
FLH72109Medicare UPIN
FL47832TMedicare PIN