Provider Demographics
NPI:1639173396
Name:TUCKER, CHARLES L (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:L
Last Name:TUCKER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:195 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:CHEROKEE VILLAGE
Mailing Address - State:AR
Mailing Address - Zip Code:72529-7314
Mailing Address - Country:US
Mailing Address - Phone:870-257-6061
Mailing Address - Fax:870-257-7667
Practice Address - Street 1:195 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:CHEROKEE VILLAGE
Practice Address - State:AR
Practice Address - Zip Code:72529-7314
Practice Address - Country:US
Practice Address - Phone:870-257-6060
Practice Address - Fax:870-257-7667
Is Sole Proprietor?:No
Enumeration Date:2005-06-10
Last Update Date:2013-07-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
ARC3379207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR105959001Medicaid
ARD04966Medicare UPIN