Provider Demographics
NPI:1679576128
Name:TUCKER, MARIANN LOUISE (OD)
Entity Type:Individual
Prefix:DR
First Name:MARIANN
Middle Name:LOUISE
Last Name:TUCKER
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3955 HUNTERS RIDGE WAY
Mailing Address - Street 2:
Mailing Address - City:TITUSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32796-1855
Mailing Address - Country:US
Mailing Address - Phone:407-658-9020
Mailing Address - Fax:800-878-9609
Practice Address - Street 1:12950 E. COLONIAL DRIVE
Practice Address - Street 2:SUITE #100
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32826-4609
Practice Address - Country:US
Practice Address - Phone:407-658-9020
Practice Address - Fax:800-878-9609
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-28
Last Update Date:2010-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC 1977152W00000X
FLFLOPC#1977152W00000X, 152WC0802X
FLFL OPC 1977152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL19281Medicare PIN
FLT84203Medicare UPIN