Provider Demographics
NPI:1659344125
Name:TUCKER, ERIC A (DPM)
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:A
Last Name:TUCKER
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4910 VAN NUYS BLVD
Mailing Address - Street 2:SUITE 307
Mailing Address - City:SHERMAN OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91403-1715
Mailing Address - Country:US
Mailing Address - Phone:818-906-2354
Mailing Address - Fax:818-906-2963
Practice Address - Street 1:4910 VAN NUYS BLVD
Practice Address - Street 2:SUITE 307
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91403-1715
Practice Address - Country:US
Practice Address - Phone:818-906-2354
Practice Address - Fax:818-906-2963
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-07
Last Update Date:2009-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE3611213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA6245450001Medicare NSC
CAE3611Medicare PIN
CAU34547Medicare UPIN