Healthcare Provider Details

I. General information

NPI: 1669453262
Provider Name (Legal Business Name): LAWRENCE VERNON TUCKER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/10/2005
Last Update Date: 09/30/2025
Certification Date: 09/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4000 MACARTHUR BLVD SUITE 600 EAST TOWER
NEWPORT BEACH CA
92660-2558
US

IV. Provider business mailing address

4000 MACARTHUR BLVD SUITE 600 EAST TOWER
NEWPORT BEACH CA
92660-2558
US

V. Phone/Fax

Practice location:
  • Phone: 949-257-4217
  • Fax: 949-627-8107
Mailing address:
  • Phone: 949-257-4217
  • Fax: 949-627-8107

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License NumberP0883
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License NumberA84067
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberA84067
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberP0883
License Number StateTX
# 5
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberA84067
License Number StateCA
# 6
Primary TaxonomyN
Taxonomy Code2084S0010X
TaxonomySports Medicine (Psychiatry & Neurology) Physician
License NumberA84067
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: