Provider Demographics
NPI:1043690860
Name:TUCKER, DERON
Entity Type:Individual
Prefix:
First Name:DERON
Middle Name:
Last Name:TUCKER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7243 TANAGER ST
Mailing Address - Street 2:
Mailing Address - City:HOBART
Mailing Address - State:IN
Mailing Address - Zip Code:46342-6948
Mailing Address - Country:US
Mailing Address - Phone:219-256-2030
Mailing Address - Fax:
Practice Address - Street 1:7243 TANAGER ST
Practice Address - Street 2:
Practice Address - City:HOBART
Practice Address - State:IN
Practice Address - Zip Code:46342-6948
Practice Address - Country:US
Practice Address - Phone:219-256-2030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-06
Last Update Date:2015-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN5360094917172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver