Provider Demographics
NPI:1285643346
Name:TUCKER, MARK ALAN (DO)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:ALAN
Last Name:TUCKER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 E. HWY 19
Mailing Address - Street 2:
Mailing Address - City:CENTER
Mailing Address - State:MO
Mailing Address - Zip Code:63436-0311
Mailing Address - Country:US
Mailing Address - Phone:573-267-3318
Mailing Address - Fax:573-267-3933
Practice Address - Street 1:401 E HWY 19
Practice Address - Street 2:
Practice Address - City:CENTER
Practice Address - State:MO
Practice Address - Zip Code:63436
Practice Address - Country:US
Practice Address - Phone:573-267-3318
Practice Address - Fax:573-267-3933
Is Sole Proprietor?:No
Enumeration Date:2006-08-07
Last Update Date:2021-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR4C62207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO241722206Medicaid
MO000001442Medicare ID - Type Unspecified
MOD41491Medicare UPIN
MO014425429Medicare PIN