Healthcare Provider Details

I. General information

NPI: 1689839813
Provider Name (Legal Business Name): JASON DAVID TUCKER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/28/2008
Last Update Date: 11/03/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12312 COPPER WAY SUITE 200
CHARLOTTE NC
28277-3386
US

IV. Provider business mailing address

12312 COPPER WAY SUITE 200
CHARLOTTE NC
28277-3386
US

V. Phone/Fax

Practice location:
  • Phone: 980-859-2340
  • Fax: 844-830-8115
Mailing address:
  • Phone: 980-859-2340
  • Fax: 844-830-8115

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number0101249850
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code213ES0000X
TaxonomySports Medicine Podiatrist
License Number01109
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: