Healthcare Provider Details

I. General information

NPI: 1548316797
Provider Name (Legal Business Name): DANIEL MCKENDREE TUCKER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/27/2007
Last Update Date: 03/22/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1920 BRIARCLIFF RD NE
ATLANTA GA
30329-4010
US

IV. Provider business mailing address

1920 BRIARCLIFF RD NE
ATLANTA GA
30329-4010
US

V. Phone/Fax

Practice location:
  • Phone: 404-785-9328
  • Fax: 404-785-9068
Mailing address:
  • Phone: 404-785-9328
  • Fax: 404-785-9068

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number19123
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberME63609
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number076838
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: