Provider Demographics
NPI:1922033372
Name:TUCKER, MICHELE RENEE (DO)
Entity type:Individual
Prefix:
First Name:MICHELE
Middle Name:RENEE
Last Name:TUCKER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 S PINE ISLAND RD STE 800
Mailing Address - Street 2:
Mailing Address - City:PLANTATION
Mailing Address - State:FL
Mailing Address - Zip Code:33324-3923
Mailing Address - Country:US
Mailing Address - Phone:863-683-4661
Mailing Address - Fax:863-683-2579
Practice Address - Street 1:2140 E EDGEWOOD DR
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33803-3604
Practice Address - Country:US
Practice Address - Phone:863-669-1212
Practice Address - Fax:863-666-6089
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2021-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34008377208000000X
FLOS 9417208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL274953000Medicaid