Healthcare Provider Details

I. General information

NPI: 1346294204
Provider Name (Legal Business Name): KENNETH B TUCKER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2006
Last Update Date: 07/19/2023
Certification Date: 07/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

180 N WATERSOUND PKWY
INLET BEACH FL
32461-7274
US

IV. Provider business mailing address

4205 BELFORT RD STE 4015
JACKSONVILLE FL
32216-3623
US

V. Phone/Fax

Practice location:
  • Phone: 850-278-3551
  • Fax: 850-378-3596
Mailing address:
  • Phone: 904-450-6063
  • Fax: 904-539-4091

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME160121
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: