Provider Demographics
NPI:1275648552
Name:TUCKER, EDWARD SPORL (MD)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:SPORL
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 1:67 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ESSEX
Mailing Address - State:CT
Mailing Address - Zip Code:06426-1074
Mailing Address - Country:US
Mailing Address - Phone:860-767-1411
Mailing Address - Fax:860-767-1233
Practice Address - Street 1:67 N MAIN ST
Practice Address - Street 2:
Practice Address - City:ESSEX
Practice Address - State:CT
Practice Address - Zip Code:06426-1074
Practice Address - Country:US
Practice Address - Phone:860-767-1411
Practice Address - Fax:860-767-1233
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-20
Last Update Date:2016-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT013972174400000X
CT139722084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT058532OtherCONNECTICARE
CT0V0648OtherHEALTH NET
CT010013972CT01OtherANTHEM BLUE CROSS
CTP2492859OtherOXFORD
CT507435OtherAETNA
CTCIGNAOtherCIGNA
CT507435OtherAETNA
CT010013972CT01OtherANTHEM BLUE CROSS