Provider Demographics
NPI:1528008133
Name:TUCKER, DOLORES R (MD)
Entity Type:Individual
Prefix:
First Name:DOLORES
Middle Name:R
Last Name:TUCKER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7724 W BILTMORE DR
Mailing Address - Street 2:
Mailing Address - City:CLAYTON
Mailing Address - State:MO
Mailing Address - Zip Code:63105-2608
Mailing Address - Country:US
Mailing Address - Phone:314-878-2556
Mailing Address - Fax:314-275-7442
Practice Address - Street 1:224 S WOODS MILL RD
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63017-3614
Practice Address - Country:US
Practice Address - Phone:314-878-2556
Practice Address - Fax:314-275-7442
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO35270174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOA24081Medicare UPIN