Provider Demographics
NPI:1568776730
Name:ELIZABETH M TUCKER DO PC
Entity Type:Organization
Organization Name:ELIZABETH M TUCKER DO PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:M
Authorized Official - Last Name:TUCKER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:575-921-5452
Mailing Address - Street 1:205 W BOUTZ RD
Mailing Address - Street 2:BLDG 1
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88005-3259
Mailing Address - Country:US
Mailing Address - Phone:575-532-7000
Mailing Address - Fax:575-532-7006
Practice Address - Street 1:1212 9TH ST
Practice Address - Street 2:SUITE A
Practice Address - City:ALAMOGORDO
Practice Address - State:NM
Practice Address - Zip Code:88310-5842
Practice Address - Country:US
Practice Address - Phone:575-439-9997
Practice Address - Fax:575-439-8080
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-30
Last Update Date:2011-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMA-1455-08208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM08929238Medicaid
NM08929238Medicaid