MEDICARE: DR. LAWRENCE VERNON TUCKER M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084P0800X	Psychiatry Physician	P0883	TX
2	2084A0401X	Addiction Medicine (Psychiatry & Neurology) Physician	P0883	TX
3	2084A0401X	Addiction Medicine (Psychiatry & Neurology) Physician	A84067	CA
4	2084S0010X	Sports Medicine (Psychiatry & Neurology) Physician	A84067	CA
5	2084P0804X	Child & Adolescent Psychiatry Physician	A84067	CA
6	2084P0800X	Psychiatry Physician	A84067	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	P0883	OTHER	TX	STATE MEDICAL LIC

General Provider Information

NPI Number	:	1669453262
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LAWRENCE VERNON TUCKER M.D.

Provider Business Mailing Address
First Line	:	4000 MACARTHUR BLVD
Second Line	:	SUITE 600 EAST TOWER
City	:	NEWPORT BEACH
State	:	CA
Zip	:	92660-2558
Country	:	US
Telephone Number	:	949-257-4217
Fax Number	:	949-627-8107

Provider Business Practice Location Address
First Line	:	4000 MACARTHUR BLVD
Second Line	:	SUITE 600 EAST TOWER
City	:	NEWPORT BEACH
State	:	CA
Zip	:	92660-2558
Country	:	US
Telephone Number	:	949-257-4217
Fax Number	:	949-627-8107

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/10/2005
Last Update Date	:	09/30/2025

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