Provider Demographics
NPI:1326072778
Name:TUCKER, WILLIAM T (MD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:T
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 1:2004 BREMO RD
Mailing Address - Street 2:STE. 201
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23226-2442
Mailing Address - Country:US
Mailing Address - Phone:804-239-1640
Mailing Address - Fax:804-239-1655
Practice Address - Street 1:2004 BREMO RD
Practice Address - Street 2:STE. 201
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23226-2442
Practice Address - Country:US
Practice Address - Phone:804-239-1640
Practice Address - Fax:804-239-1655
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2022-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101033528207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA005610303Medicaid
VA4073378OtherAETNA HMO
VA57302OtherSOUTHERN HEALTH SERVICES
VA4073378OtherAETNA LIFE
VA010420024OtherMEDICAID OF VA
VA1326072778Medicaid
VA085091OtherANTHEM BCBS OF VA
VA1459024OtherCIGNA
VA43286OtherSENTARA
VA1459024OtherCIGNA
VA57302OtherSOUTHERN HEALTH SERVICES