Provider Demographics
NPI:1518974393
Name:TUCKER, HENRY (MD)
Entity Type:Individual
Prefix:DR
First Name:HENRY
Middle Name:
Last Name:TUCKER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:440 DANBURY LN
Mailing Address - Street 2:A
Mailing Address - City:COPLEY
Mailing Address - State:OH
Mailing Address - Zip Code:44321-2963
Mailing Address - Country:US
Mailing Address - Phone:216-650-2542
Mailing Address - Fax:886-436-5298
Practice Address - Street 1:440 DANBURY LN
Practice Address - Street 2:STE A
Practice Address - City:COPLEY
Practice Address - State:OH
Practice Address - Zip Code:44321-2963
Practice Address - Country:US
Practice Address - Phone:216-650-2542
Practice Address - Fax:866-436-5298
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2009-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301082941207R00000X
OH35 042047207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4847591Medicaid
OH0781444Medicaid
OH2021531Medicare PIN
MIE29089Medicare UPIN
MIM40150132Medicare ID - Type Unspecified