Healthcare Provider Details

I. General information

NPI: 1851772289
Provider Name (Legal Business Name): JAMES EDWIN TUCKER DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/11/2015
Last Update Date: 07/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6500 HOSPITAL DR
HANNIBAL MO
63401
US

IV. Provider business mailing address

PO BOX 1239
HANNIBAL MO
63401-1239
US

V. Phone/Fax

Practice location:
  • Phone: 573-629-3440
  • Fax: 573-629-3423
Mailing address:
  • Phone: 573-629-3440
  • Fax: 573-629-3423

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2015017297
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2016033286
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: