Healthcare Provider Details

I. General information

NPI: 1730184805
Provider Name (Legal Business Name): KENNETH D TUCK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2005
Last Update Date: 11/19/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3320 FRANKLIN RD SW
ROANOKE VA
24014-1310
US

IV. Provider business mailing address

PO BOX 1789
ROANOKE VA
24008-1789
US

V. Phone/Fax

Practice location:
  • Phone: 540-855-5100
  • Fax:
Mailing address:
  • Phone: 540-855-5100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number0101013638
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: