Provider Demographics
NPI:1467676411
Name:TUCKEY, MICHAEL DOUGLAS (DC)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:DOUGLAS
Last Name:TUCKEY
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5023 E 56TH ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46226-1474
Mailing Address - Country:US
Mailing Address - Phone:317-351-0345
Mailing Address - Fax:
Practice Address - Street 1:5023 E 56TH ST
Practice Address - Street 2:SUITE 100
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46226-1474
Practice Address - Country:US
Practice Address - Phone:317-351-0345
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08001328111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN0000000353133OtherBCBS
IN712290Medicare ID - Type Unspecified
IN0000000353133OtherBCBS