MEDICARE: DR. MARIANN LOUISE TUCKER O.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	152W00000X	Optometrist	OPC 1977	FL
2	152W00000X	Optometrist	FLOPC#1977	FL
3	152WC0802X	Corneal and Contact Management Optometrist	FLOPC#1977	FL
4	152WC0802X	Corneal and Contact Management Optometrist	FL OPC 1977	FL

General Provider Information

NPI Number	:	1679576128
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARIANN LOUISE TUCKER O.D.

Provider Business Mailing Address
First Line	:	3955 HUNTERS RIDGE WAY
Second Line	:
City	:	TITUSVILLE
State	:	FL
Zip	:	32796-1855
Country	:	US
Telephone Number	:	407-658-9020
Fax Number	:	800-878-9609

Provider Business Practice Location Address
First Line	:	12950 E. COLONIAL DRIVE
Second Line	:	SUITE #100
City	:	ORLANDO
State	:	FL
Zip	:	32826-4609
Country	:	US
Telephone Number	:	407-658-9020
Fax Number	:	800-878-9609

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

Provider Enumeration Date	:	05/28/2005
Last Update Date	:	04/19/2010

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