Provider Demographics
NPI:1669453262
Name:TUCKER, LAWRENCE VERNON (MD)
Entity Type:Individual
Prefix:DR
First Name:LAWRENCE
Middle Name:VERNON
Last Name:TUCKER
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:4000 MACARTHUR BLVD
Mailing Address - Street 2:SUITE 600 EAST TOWER
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-2558
Mailing Address - Country:US
Mailing Address - Phone:949-257-4217
Mailing Address - Fax:949-627-8107
Practice Address - Street 1:4000 MACARTHUR BLVD
Practice Address - Street 2:SUITE 600 EAST TOWER
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-2558
Practice Address - Country:US
Practice Address - Phone:949-257-4217
Practice Address - Fax:949-627-8107
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-10
Last Update Date:2022-05-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXP08832084A0401X, 2084P0800X
CAA840672084P0800X, 2084P0804X, 2084S0010X, 2084A0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084A0401XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Medicine
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No2084S0010XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP0883OtherSTATE MEDICAL LIC
CAI38963Medicare UPIN
CAA84067Medicare PIN