Provider Demographics
NPI:1487695904
Name:TUCKER, DONALD V (MD)
Entity type:Individual
Prefix:
First Name:DONALD
Middle Name:V
Last Name:TUCKER
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 1:100 WILLIAM NORTHERN BLVD
Mailing Address - Street 2:
Mailing Address - City:TULLAHOMA
Mailing Address - State:TN
Mailing Address - Zip Code:37388-4754
Mailing Address - Country:US
Mailing Address - Phone:931-454-0489
Mailing Address - Fax:
Practice Address - Street 1:100 WILLIAM NORTHERN BLVD
Practice Address - Street 2:
Practice Address - City:TULLAHOMA
Practice Address - State:TN
Practice Address - Zip Code:37388-2201
Practice Address - Country:US
Practice Address - Phone:931-454-0492
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2013-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN024197207P00000X
TNMD024197207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3832134Medicaid
TNF49592Medicare UPIN
TN3832134Medicaid