Provider Demographics
NPI:1346294204
Name:TUCKER, KENNETH B (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:B
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 1:4205 BELFORT RD STE 4015
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-3623
Mailing Address - Country:US
Mailing Address - Phone:904-450-6063
Mailing Address - Fax:904-539-4091
Practice Address - Street 1:180 N WATERSOUND PKWY
Practice Address - Street 2:
Practice Address - City:INLET BEACH
Practice Address - State:FL
Practice Address - Zip Code:32461-7274
Practice Address - Country:US
Practice Address - Phone:850-278-3551
Practice Address - Fax:850-378-3596
Is Sole Proprietor?:No
Enumeration Date:2006-05-22
Last Update Date:2023-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME160121207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51040677OtherBCBS
GA000810983BMedicaid
AL000040677Medicaid
AL000076854Medicare PIN
AL51040677OtherBCBS
AL000040677Medicare ID - Type Unspecified