Healthcare Provider Details

I. General information

NPI: 1578664462
Provider Name (Legal Business Name): SUSAN MARY TUCKER M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2006
Last Update Date: 05/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 ESSEX CENTER DR LAHEY CLINIC
PEABODY MA
01960-2901
US

IV. Provider business mailing address

1 ESSEX CENTER DRIVE LAHEY CLINIC
PEABODY MA
01960-2901
US

V. Phone/Fax

Practice location:
  • Phone: 978-538-4400
  • Fax: 978-538-4724
Mailing address:
  • Phone: 978-538-4400
  • Fax: 978-538-4724

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number156646
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code207WX0200X
TaxonomyOphthalmic Plastic and Reconstructive Surgery Physician
License Number156646
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: