Provider Demographics
NPI:1528027802
Name:TUCKER, STANLEY C (MD)
Entity Type:Individual
Prefix:
First Name:STANLEY
Middle Name:C
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 1:8401 N RUN MEDICAL DR
Mailing Address - Street 2:
Mailing Address - City:MECHANICSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:23116-2309
Mailing Address - Country:US
Mailing Address - Phone:804-559-9902
Mailing Address - Fax:804-559-9904
Practice Address - Street 1:8401 N RUN MEDICAL DR
Practice Address - Street 2:
Practice Address - City:MECHANICSVILLE
Practice Address - State:VA
Practice Address - Zip Code:23116-2309
Practice Address - Country:US
Practice Address - Phone:804-559-9902
Practice Address - Fax:804-559-9904
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-23
Last Update Date:2019-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101019973207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA005812836Medicaid
VA005812836Medicaid
B05645Medicare UPIN