Healthcare Provider Details

I. General information

NPI: 1265639306
Provider Name (Legal Business Name): ELLIOT MOORE TUCKER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2007
Last Update Date: 12/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 CHILDRENS LN
NORFOLK VA
23507-1910
US

IV. Provider business mailing address

601 CHILDRENS LN
NORFOLK VA
23507-1910
US

V. Phone/Fax

Practice location:
  • Phone: 757-668-7213
  • Fax:
Mailing address:
  • Phone: 757-668-7213
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License Number0101234827
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: