Provider Demographics
NPI:1033189501
Name:TUCKER, CHARLES L (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:L
Last Name:TUCKER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:724 ARDEN LANE
Mailing Address - Street 2:SUITE 220
Mailing Address - City:ROCK HILL
Mailing Address - State:SC
Mailing Address - Zip Code:29732
Mailing Address - Country:US
Mailing Address - Phone:803-323-2020
Mailing Address - Fax:803-329-7897
Practice Address - Street 1:724 ARDEN LANE
Practice Address - Street 2:SUITE 220
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29732
Practice Address - Country:US
Practice Address - Phone:803-323-2020
Practice Address - Fax:803-329-7897
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2022-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC28369207WX0107X
NC51916207WX0107X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC283696Medicaid
1861433013OtherRAILROAD MEDICARE
NC5903003Medicaid
SCH599517541Medicare PIN
H59951Medicare UPIN
NC2048282Medicare PIN