Provider Demographics
NPI:1033301205
Name:LETICIA K. TUCKER, M.D., L.L.C.
Entity Type:Organization
Organization Name:LETICIA K. TUCKER, M.D., L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DR.
Authorized Official - Prefix:
Authorized Official - First Name:LETICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:TUCKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:270-298-5164
Mailing Address - Street 1:1215 OLD MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:KY
Mailing Address - Zip Code:42347-1619
Mailing Address - Country:US
Mailing Address - Phone:270-298-5164
Mailing Address - Fax:270-298-5285
Practice Address - Street 1:1215 OLD MAIN ST
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:KY
Practice Address - Zip Code:42347-1619
Practice Address - Country:US
Practice Address - Phone:270-298-5164
Practice Address - Fax:270-298-5285
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-13
Last Update Date:2007-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY37109207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
H65574Medicare UPIN
KY0720501Medicare PIN