Healthcare Provider Details

I. General information

NPI: 1790704203
Provider Name (Legal Business Name): MARK H TUCKER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2006
Last Update Date: 11/06/2025
Certification Date: 11/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15004 INNOVATION DR
SAN DIEGO CA
92128-3491
US

IV. Provider business mailing address

10790 RANCHO BERNARDO RD
SAN DIEGO CA
92127-5705
US

V. Phone/Fax

Practice location:
  • Phone: 858-605-7169
  • Fax:
Mailing address:
  • Phone: 858-605-7169
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License NumberA67916
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: