Provider Demographics
NPI:1376778332
Name:MICHAEL G. TUCKER, DPM
Entity Type:Organization
Organization Name:MICHAEL G. TUCKER, DPM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:GEORGE
Authorized Official - Last Name:TUCKER
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:979-285-0505
Mailing Address - Street 1:450 THIS WAY ST
Mailing Address - Street 2:SUITE D
Mailing Address - City:LAKE JACKSON
Mailing Address - State:TX
Mailing Address - Zip Code:77566-5152
Mailing Address - Country:US
Mailing Address - Phone:979-285-0505
Mailing Address - Fax:979-285-9355
Practice Address - Street 1:450 THIS WAY ST
Practice Address - Street 2:SUITE D
Practice Address - City:LAKE JACKSON
Practice Address - State:TX
Practice Address - Zip Code:77566-5152
Practice Address - Country:US
Practice Address - Phone:979-285-0505
Practice Address - Fax:979-285-9355
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-20
Last Update Date:2009-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1302332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00T68LOtherBCBS
TX127186802Medicaid
TX00T68LOtherBCBS
TX127186802Medicaid
TX00141JMedicare PIN