=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679576128
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARIANN LOUISE TUCKER O.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/28/2005
-----------------------------------------------------
Last Update Date | 04/19/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12950 E. COLONIAL DRIVE SUITE #100
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32826-4609
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-658-9020
-----------------------------------------------------
Fax | 800-878-9609
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3955 HUNTERS RIDGE WAY
-----------------------------------------------------
City | TITUSVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32796-1855
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-658-9020
-----------------------------------------------------
Fax | 800-878-9609
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | OPC 1977
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | FLOPC#1977
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 152WC0802X
-----------------------------------------------------
Taxonomy Name | Corneal and Contact Management Optometrist
-----------------------------------------------------
License Number | FLOPC#1977
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 152WC0802X
-----------------------------------------------------
Taxonomy Name | Corneal and Contact Management Optometrist
-----------------------------------------------------
License Number | FL OPC 1977
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------