Provider Demographics
NPI:1245586296
Name:TUCKER, KINDRELL S (MD)
Entity Type:Individual
Prefix:
First Name:KINDRELL
Middle Name:S
Last Name:TUCKER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 154137
Mailing Address - Street 2:
Mailing Address - City:LUFKIN
Mailing Address - State:TX
Mailing Address - Zip Code:75915-4137
Mailing Address - Country:US
Mailing Address - Phone:936-225-3657
Mailing Address - Fax:936-899-7293
Practice Address - Street 1:1320 S JOHN REDDITT DR STE B
Practice Address - Street 2:
Practice Address - City:LUFKIN
Practice Address - State:TX
Practice Address - Zip Code:75904-4368
Practice Address - Country:US
Practice Address - Phone:936-225-3657
Practice Address - Fax:936-899-7293
Is Sole Proprietor?:No
Enumeration Date:2012-07-27
Last Update Date:2020-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXQ3822207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
1245586296OtherTYPE I NATIONAL PROVIDER IDENTIFIER
1467988600OtherTYPE II NATIONAL PROVIDER IDENTIFIER