=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568747244
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LAWRENCE V. TUCKER, M.D., PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/13/2011
-----------------------------------------------------
Last Update Date | 12/25/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5000 LEGACY DR SUITE 400
-----------------------------------------------------
City | PLANO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75024-3100
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-473-7628
-----------------------------------------------------
Fax | 972-473-7699
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5000 LEGACY DR SUITE 400
-----------------------------------------------------
City | PLANO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75024-3100
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-473-7628
-----------------------------------------------------
Fax | 972-473-7699
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO/PSYCHIATRIST
-----------------------------------------------------
Name | DR. LAWRENCE VERNON TUCKER
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 888-972-2178
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084A0401X
-----------------------------------------------------
Taxonomy Name | Addiction Medicine (Psychiatry & Neurology) Physician
-----------------------------------------------------
License Number | A84067
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2084A0401X
-----------------------------------------------------
Taxonomy Name | Addiction Medicine (Psychiatry & Neurology) Physician
-----------------------------------------------------
License Number | P0883
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 2084B0040X
-----------------------------------------------------
Taxonomy Name | Behavioral Neurology & Neuropsychiatry Physician
-----------------------------------------------------
License Number | P0883
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | A84067
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | P0883
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #6
-----------------------------------------------------
Taxonomy Code | 2084P2900X
-----------------------------------------------------
Taxonomy Name | Pain Medicine (Psychiatry & Neurology) Physician
-----------------------------------------------------
License Number | P0883
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #7
-----------------------------------------------------
Taxonomy Code | 2084S0010X
-----------------------------------------------------
Taxonomy Name | Sports Medicine (Psychiatry & Neurology) Physician
-----------------------------------------------------
License Number | P0883
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------