Provider Demographics
NPI:1164402053
Name:TUCKER, ELMO GLENN (MD)
Entity Type:Individual
Prefix:MR
First Name:ELMO
Middle Name:GLENN
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:P.O. BOX 287
Mailing Address - Street 2:118 NORTHPORT AVE
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915
Mailing Address - Country:US
Mailing Address - Phone:207-338-9324
Mailing Address - Fax:207-338-6820
Practice Address - Street 1:118 NORTHPORT AVE
Practice Address - Street 2:
Practice Address - City:BELFAST
Practice Address - State:ME
Practice Address - Zip Code:04915
Practice Address - Country:US
Practice Address - Phone:207-338-9324
Practice Address - Fax:207-338-6820
Is Sole Proprietor?:No
Enumeration Date:2006-01-18
Last Update Date:2015-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT029674207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTE42362Medicare UPIN