Provider Demographics
NPI:1538130836
Name:TUCKER, IAN STERLING (MD)
Entity Type:Individual
Prefix:DR
First Name:IAN
Middle Name:STERLING
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:PO BOX 959
Mailing Address - Street 2:
Mailing Address - City:SOMERS
Mailing Address - State:CT
Mailing Address - Zip Code:06071-4059
Mailing Address - Country:US
Mailing Address - Phone:860-749-8887
Mailing Address - Fax:860-749-7421
Practice Address - Street 1:24 BATTLE ST
Practice Address - Street 2:SUITE 1A
Practice Address - City:SOMERS
Practice Address - State:CT
Practice Address - Zip Code:06071-1629
Practice Address - Country:US
Practice Address - Phone:860-749-8887
Practice Address - Fax:860-749-7421
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-27
Last Update Date:2013-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT039732207Q00000X
CT39732208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001397323Medicaid
CTH08583Medicare UPIN
CT001397323Medicaid