Provider Demographics
NPI:1629090964
Name:TUCKER, WILSON LARRY (MD)
Entity Type:Individual
Prefix:
First Name:WILSON
Middle Name:LARRY
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 1:420 E 2ND AVE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30161-3224
Mailing Address - Country:US
Mailing Address - Phone:706-509-3000
Mailing Address - Fax:706-509-4608
Practice Address - Street 1:304 SHORTER AVE NW
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30165-4290
Practice Address - Country:US
Practice Address - Phone:706-291-3700
Practice Address - Fax:706-291-8712
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2014-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA031142207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00375229SMedicaid
GA00375229SMedicaid