Provider Demographics
NPI:1083814297
Name:TUCKER, JOHN D
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:D
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 1:9985 SIERRA AVE
Mailing Address - Street 2:BLDG. #3, DEPT. OF RADIOLOGY
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92335-6720
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9985 SIERRA AVE
Practice Address - Street 2:BLDG. #3, DEPT. OF RADIOLOGY
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92335-6720
Practice Address - Country:US
Practice Address - Phone:909-427-7649
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-25
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD280772085R0202X
AK62512085R0202X
PAMT1906802085R0204X
CAA854842085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR141725Medicare PIN
ORR141723Medicare PIN
ORR141724Medicare PIN
AKK161744Medicare PIN