Provider Demographics
NPI:1689630295
Name:TUCKER, GEOFFREY A (MD)
Entity Type:Individual
Prefix:DR
First Name:GEOFFREY
Middle Name:A
Last Name:TUCKER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2080 CENTURY PARK EAST
Mailing Address - Street 2:STE 902
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90067
Mailing Address - Country:US
Mailing Address - Phone:310-556-0263
Mailing Address - Fax:310-556-0278
Practice Address - Street 1:2080 CENTURY PARK EAST
Practice Address - Street 2:STE 902
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90067
Practice Address - Country:US
Practice Address - Phone:310-556-0263
Practice Address - Fax:310-556-0278
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG164262084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
E96000Medicare UPIN