Healthcare Provider Details

I. General information

NPI: 1144219239
Provider Name (Legal Business Name): JOHN TUCKER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/20/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

790 CHURCH ST NE SUITE 570
MARIETTA GA
30060-7282
US

IV. Provider business mailing address

790 CHURCH ST NE SUITE 570
MARIETTA GA
30060-7282
US

V. Phone/Fax

Practice location:
  • Phone: 770-428-0462
  • Fax: 770-427-8001
Mailing address:
  • Phone: 770-428-0462
  • Fax: 770-427-8001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number020492
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: