Provider Demographics
NPI:1093993404
Name:TUCKER, MICHELLE S (MD)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:S
Last Name:TUCKER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1821 GOLDEN TRAIL CT STE 200
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:TX
Mailing Address - Zip Code:75010-4675
Mailing Address - Country:US
Mailing Address - Phone:972-492-2222
Mailing Address - Fax:972-492-4453
Practice Address - Street 1:1821 GOLDEN TRAIL CT STE 200
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:TX
Practice Address - Zip Code:75010-4675
Practice Address - Country:US
Practice Address - Phone:972-492-2222
Practice Address - Fax:972-492-4453
Is Sole Proprietor?:No
Enumeration Date:2008-02-07
Last Update Date:2008-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL6687208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX190764401Medicaid