Provider Demographics
NPI:1629113915
Name:TUCKLER MEDICAL CENTER
Entity Type:Organization
Organization Name:TUCKLER MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:DOMINGO
Authorized Official - Middle Name:
Authorized Official - Last Name:TUCKLER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:305-274-4031
Mailing Address - Street 1:PO BOX 651250
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33265-1250
Mailing Address - Country:US
Mailing Address - Phone:305-274-4031
Mailing Address - Fax:305-274-4032
Practice Address - Street 1:8410 W FLAGLER ST
Practice Address - Street 2:SUITE 215-B
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33144-2092
Practice Address - Country:US
Practice Address - Phone:305-274-4031
Practice Address - Fax:305-274-4032
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME66056207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL26526Medicare ID - Type Unspecified