Provider Demographics
NPI:1215228499
Name:MUDRICK, TUCKER RANDOLPH (MD)
Entity Type:Individual
Prefix:
First Name:TUCKER
Middle Name:RANDOLPH
Last Name:MUDRICK
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:PO BOX 34717
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78265-4717
Mailing Address - Country:US
Mailing Address - Phone:210-615-1187
Mailing Address - Fax:210-614-2180
Practice Address - Street 1:4242 MEDICAL DR
Practice Address - Street 2:SUITE 3100
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-5640
Practice Address - Country:US
Practice Address - Phone:210-615-1187
Practice Address - Fax:210-614-2180
Is Sole Proprietor?:No
Enumeration Date:2011-04-22
Last Update Date:2015-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TXQ4220207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX3486177-01Medicaid