Healthcare Provider Details

I. General information

NPI: 1942382957
Provider Name (Legal Business Name): WILLIAM TUCKER D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/19/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2240 E. WINROW AVE ., ATTN: MCXJ-CREDENTIALS USA MEDDAC, RWBAHC
FORT HUACHUCA AZ
85613-7079
US

IV. Provider business mailing address

1482 E LOMA LN
SIERRA VISTA AZ
85650-8814
US

V. Phone/Fax

Practice location:
  • Phone: 520-533-1696
  • Fax: 520-533-7099
Mailing address:
  • Phone: 520-533-5055
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License NumberDO-66
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: