Provider Demographics
NPI:1629232418
Name:HARRIS, TUCKER MARTIN (MD)
Entity Type:Individual
Prefix:DR
First Name:TUCKER
Middle Name:MARTIN
Last Name:HARRIS
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 1:4000 MEDICAL CENTER DR # 117
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13066-6631
Mailing Address - Country:US
Mailing Address - Phone:315-744-1505
Mailing Address - Fax:315-214-1924
Practice Address - Street 1:4000 MEDICAL CENTER DR # 117
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NY
Practice Address - Zip Code:13066
Practice Address - Country:US
Practice Address - Phone:315-744-1505
Practice Address - Fax:315-214-1924
Is Sole Proprietor?:No
Enumeration Date:2008-07-11
Last Update Date:2018-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY258471207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY258471OtherLICENSE
NY03274408Medicaid