Provider Demographics
NPI:1205861135
Name:TUCKER, ALTON GLENN (MD)
Entity Type:Individual
Prefix:DR
First Name:ALTON
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 1:8991 COTSWOLD DRIVE
Mailing Address - Street 2:
Mailing Address - City:BURKE
Mailing Address - State:VA
Mailing Address - Zip Code:22015
Mailing Address - Country:US
Mailing Address - Phone:703-440-4050
Mailing Address - Fax:703-440-8246
Practice Address - Street 1:8991 COTSWOLD DRIVE
Practice Address - Street 2:
Practice Address - City:BURKE
Practice Address - State:VA
Practice Address - Zip Code:22015
Practice Address - Country:US
Practice Address - Phone:703-440-4050
Practice Address - Fax:703-440-8246
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2012-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA101029876207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA005620643Medicaid
080184637Medicare ID - Type Unspecified
C62402Medicare UPIN