Provider Demographics
NPI:1225092471
Name:TUCKER, CHARLES HOWELL (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:HOWELL
Last Name:TUCKER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3225 CUMBERLAND BLVD SE
Mailing Address - Street 2:SUITE 900
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30339-6407
Mailing Address - Country:US
Mailing Address - Phone:404-351-2220
Mailing Address - Fax:404-355-5624
Practice Address - Street 1:340 BRANDYWINE BLVD
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-1562
Practice Address - Country:US
Practice Address - Phone:770-460-4286
Practice Address - Fax:770-460-4016
Is Sole Proprietor?:No
Enumeration Date:2006-04-14
Last Update Date:2019-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA027255207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
18BDFFLOtherMEDICARE ID
GA000332835HMedicaid
18BDFFLOtherMEDICARE ID
GA000332835HMedicaid
GA00965Medicare PIN