Provider Demographics
NPI:1033217591
Name:TUCKER, DAVID M (PHD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:M
Last Name:TUCKER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:711 W 38TH ST
Mailing Address - Street 2:BLDG. F
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78705-1121
Mailing Address - Country:US
Mailing Address - Phone:512-458-6121
Mailing Address - Fax:512-452-5567
Practice Address - Street 1:711 W 38TH ST
Practice Address - Street 2:BLDG. F
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78705-1121
Practice Address - Country:US
Practice Address - Phone:512-458-6121
Practice Address - Fax:512-452-5567
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2010-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2 4175103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1004970 02Medicaid
TX8F4432OtherMEDICARE
TXR00778Medicare UPIN
TX8F4432Medicare PIN