Provider Demographics
NPI:1063508299
Name:TUCKER FAMILY MEDICINE OF ARKANSAS, INC
Entity Type:Organization
Organization Name:TUCKER FAMILY MEDICINE OF ARKANSAS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:L
Authorized Official - Last Name:TUCKER
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:870-405-8579
Mailing Address - Street 1:103 SOMERSET
Mailing Address - Street 2:
Mailing Address - City:BENTONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72712-4091
Mailing Address - Country:US
Mailing Address - Phone:479-270-8970
Mailing Address - Fax:
Practice Address - Street 1:2905 S WALTON BLVD
Practice Address - Street 2:STE. 17
Practice Address - City:BENTONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72712-6730
Practice Address - Country:US
Practice Address - Phone:870-405-8579
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-05
Last Update Date:2012-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR158496002Medicaid
AR158496002Medicaid