Provider Demographics
NPI:1093734501
Name:TUCKER, KIRK M (MD)
Entity Type:Individual
Prefix:
First Name:KIRK
Middle Name:M
Last Name:TUCKER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1715 BROWN ST.
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45409-2624
Mailing Address - Country:US
Mailing Address - Phone:937-208-9010
Mailing Address - Fax:937-208-9020
Practice Address - Street 1:1715 BROWN ST.
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45409-2624
Practice Address - Country:US
Practice Address - Phone:937-208-9010
Practice Address - Fax:937-208-9020
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2023-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35080892207R00000X
OH35.080892207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2336001Medicaid
OHH66211Medicare UPIN
OH4088056Medicare PIN