MEDICARE: KENNETH D TUCK MD

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	207W00000X	Ophthalmology Physician	0101013638	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1730184805
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KENNETH D TUCK MD

Provider Business Mailing Address
First Line	:	PO BOX 1789
Second Line	:
City	:	ROANOKE
State	:	VA
Zip	:	24008-1789
Country	:	US
Telephone Number	:	540-855-5100
Fax Number	:

Provider Business Practice Location Address
First Line	:	3320 FRANKLIN RD SW
Second Line	:
City	:	ROANOKE
State	:	VA
Zip	:	24014-1310
Country	:	US
Telephone Number	:	540-855-5100
Fax Number	:

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

Provider Enumeration Date	:	06/16/2005
Last Update Date	:	11/19/2009

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