Healthcare Provider Details

I. General information

NPI: 1679576128
Provider Name (Legal Business Name): MARIANN LOUISE TUCKER O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/28/2005
Last Update Date: 04/19/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12950 E. COLONIAL DRIVE SUITE #100
ORLANDO FL
32826-4609
US

IV. Provider business mailing address

3955 HUNTERS RIDGE WAY
TITUSVILLE FL
32796-1855
US

V. Phone/Fax

Practice location:
  • Phone: 407-658-9020
  • Fax: 800-878-9609
Mailing address:
  • Phone: 407-658-9020
  • Fax: 800-878-9609

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPC 1977
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberFLOPC#1977
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License NumberFLOPC#1977
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License NumberFL OPC 1977
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: