Provider Demographics
NPI:1033100060
Name:TUCKER, TERRY L (OD)
Entity Type:Individual
Prefix:
First Name:TERRY
Middle Name:L
Last Name:TUCKER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:88 PINE ISLAND RD
Mailing Address - Street 2:SUITE 3
Mailing Address - City:NORTH FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33903-3745
Mailing Address - Country:US
Mailing Address - Phone:239-656-1778
Mailing Address - Fax:239-656-5858
Practice Address - Street 1:88 PINE ISLAND RD
Practice Address - Street 2:SUITE 3
Practice Address - City:NORTH FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33903-3745
Practice Address - Country:US
Practice Address - Phone:239-656-1778
Practice Address - Fax:239-656-5858
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-31
Last Update Date:2008-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL2000152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL078400100Medicaid
FL0678810001Medicare NSC
FL078400100Medicaid
FLT54788Medicare UPIN