Provider Demographics
NPI:1467712943
Name:TUCKER, BRYAN MICHAEL (DO, MS)
Entity Type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:MICHAEL
Last Name:TUCKER
Suffix:
Gender:M
Credentials:DO, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:MEDICAL CENTER BOULEVARD
Mailing Address - Street 2:WAKE FOREST BAPTIST HEALTH- NEPHROLOGY
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27101
Mailing Address - Country:US
Mailing Address - Phone:336-716-4650
Mailing Address - Fax:
Practice Address - Street 1:MEDICAL CENTER BOULEVARD
Practice Address - Street 2:WAKE FOREST BAPTIST HEALTH- NEPHROLOGY
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27101
Practice Address - Country:US
Practice Address - Phone:203-688-4242
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-18
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN390200000207R00000X
390200000X
NC2017-00156207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program