=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487608345
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ELIZABETH B TUCKER MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/22/2006
-----------------------------------------------------
Last Update Date | 07/19/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12805 US HIGHWAY 98 E UNIT G201
-----------------------------------------------------
City | INLET BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32461-9632
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-278-3466
-----------------------------------------------------
Fax | 850-278-3467
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4205 BELFORT RD STE 4015
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32216-3623
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-450-6063
-----------------------------------------------------
Fax | 904-539-4091
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | ME160145
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------