Provider Demographics
NPI:1104822659
Name:TUCKER, CHRISTOPHER JOHN (DO)
Entity Type:Individual
Prefix:DR
First Name:CHRISTOPHER
Middle Name:JOHN
Last Name:TUCKER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2535 IRA E WOODS AVENUE
Mailing Address - Street 2:
Mailing Address - City:GRAPEVINE
Mailing Address - State:TX
Mailing Address - Zip Code:76051-3930
Mailing Address - Country:US
Mailing Address - Phone:817-481-2121
Mailing Address - Fax:817-488-4493
Practice Address - Street 1:2535 IRA E WOODS AVENUE
Practice Address - Street 2:
Practice Address - City:GRAPEVINE
Practice Address - State:TX
Practice Address - Zip Code:76051-3930
Practice Address - Country:US
Practice Address - Phone:817-481-2121
Practice Address - Fax:817-488-4493
Is Sole Proprietor?:No
Enumeration Date:2005-06-21
Last Update Date:2020-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ2823208100000X, 208VP0000X
TXJ2828208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX098913901Medicaid
TX82X724OtherBLUE CROSS BLUE SHIELD
TX82X724OtherBLUE CROSS BLUE SHIELD
TX00R64RMedicare ID - Type Unspecified
F41959Medicare UPIN
TX82X724Medicare PIN