=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497054068
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AARON TUCKLER MDPA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/22/2011
-----------------------------------------------------
Last Update Date | 03/22/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9570 SW 107TH AVE # C204
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33176-2788
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-598-6464
-----------------------------------------------------
Fax | 305-598-6443
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9570 SW 107TH AVE # C204
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33176-2788
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-598-6464
-----------------------------------------------------
Fax | 305-598-6443
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. AARON TUCKLER
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 305-598-6464
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number | 037558
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------