Provider Demographics
NPI:1245398510
Name:TUCKER, LYNN R (OD)
Entity Type:Individual
Prefix:DR
First Name:LYNN
Middle Name:R
Last Name:TUCKER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2020 JACKSON BLVD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57702-3484
Mailing Address - Country:US
Mailing Address - Phone:605-342-0777
Mailing Address - Fax:605-342-7282
Practice Address - Street 1:2020 JACKSON BLVD
Practice Address - Street 2:SUITE 1
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57702-3484
Practice Address - Country:US
Practice Address - Phone:605-342-0777
Practice Address - Fax:605-342-7282
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2015-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD459152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD9202543Medicaid
SDU10368Medicare UPIN
SD40354Medicare PIN