Provider Demographics
NPI:1164957478
Name:TUCKERMAN, DANIEL MARC (DO)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:MARC
Last Name:TUCKERMAN
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 1:210 BAL CROSS DR
Mailing Address - Street 2:
Mailing Address - City:BAL HARBOUR
Mailing Address - State:FL
Mailing Address - Zip Code:33154-1319
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2001 W 68TH ST
Practice Address - Street 2:SUITE 202
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33016-1801
Practice Address - Country:US
Practice Address - Phone:305-364-2107
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-24
Last Update Date:2019-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS15636207R00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program