Provider Demographics
NPI:1003264904
Name:TUCKER, KATIE KUBERG (DO)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:KUBERG
Last Name:TUCKER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22136 MEDICAL VILLAGE DRIVE
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:AL
Mailing Address - Zip Code:35613-2940
Mailing Address - Country:US
Mailing Address - Phone:256-648-5598
Mailing Address - Fax:833-603-1295
Practice Address - Street 1:22136 MEDICAL VILLAGE DRIVE
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:AL
Practice Address - Zip Code:35613
Practice Address - Country:US
Practice Address - Phone:256-648-5598
Practice Address - Fax:833-603-1295
Is Sole Proprietor?:No
Enumeration Date:2016-06-01
Last Update Date:2020-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALDO.2031208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics