Provider Demographics
NPI:1437203569
Name:TUCKER, IRA STEPHEN (OD)
Entity Type:Individual
Prefix:DR
First Name:IRA
Middle Name:STEPHEN
Last Name:TUCKER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:570 NEW WAVERLY PL
Mailing Address - Street 2:SUITE 110
Mailing Address - City:CARY
Mailing Address - State:NC
Mailing Address - Zip Code:27511-7405
Mailing Address - Country:US
Mailing Address - Phone:919-858-7555
Mailing Address - Fax:919-858-8455
Practice Address - Street 1:570 NEW WAVERLY PL
Practice Address - Street 2:SUITE 110
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27511-7405
Practice Address - Country:US
Practice Address - Phone:919-858-7555
Practice Address - Fax:919-858-8455
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC977152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC246511Medicare ID - Type UnspecifiedPROVIDER ID