Provider Demographics
NPI:1346463205
Name:KING-TUCKER, REBECCA SUZANNA (MD)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:SUZANNA
Last Name:KING-TUCKER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:SUZANNA
Other - Last Name:KING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:110 W HONEY CREEK PKWY
Mailing Address - Street 2:
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47802-4114
Mailing Address - Country:US
Mailing Address - Phone:812-232-2890
Mailing Address - Fax:317-988-5511
Practice Address - Street 1:110 W HONEY CREEK PKWY
Practice Address - Street 2:
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47802-4114
Practice Address - Country:US
Practice Address - Phone:812-232-2890
Practice Address - Fax:317-988-5511
Is Sole Proprietor?:No
Enumeration Date:2007-04-10
Last Update Date:2016-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01077239A207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
011003081OtherMEDICARE PTAN
OR171576OtherOREGON MEDICAL LICENSE
OR500628245Medicaid
011003081OtherMEDICARE PTAN
ORR180695Medicare PIN
G97361Medicare UPIN