Healthcare Provider Details

I. General information

NPI: 1639564107
Provider Name (Legal Business Name): ELIZABETH TUCKER MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/01/2015
Last Update Date: 12/31/2020
Certification Date: 12/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 KINGS HWY PEDIATRIC MEDICINE
SHREVEPORT LA
71103
US

IV. Provider business mailing address

16140 ZION HILL RD
ANDALUSIA AL
36421-1421
US

V. Phone/Fax

Practice location:
  • Phone: 318-675-8600
  • Fax: 318-675-8601
Mailing address:
  • Phone: 206-687-2745
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number37403
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: