Provider Demographics
NPI:1740232636
Name:TUCKER, SALLY I (MD)
Entity Type:Individual
Prefix:DR
First Name:SALLY
Middle Name:I
Last Name:TUCKER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 32849
Mailing Address - Street 2:DEPT 274
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28232-2849
Mailing Address - Country:US
Mailing Address - Phone:540-932-4465
Mailing Address - Fax:
Practice Address - Street 1:78 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:FISHERSVILLE
Practice Address - State:VA
Practice Address - Zip Code:22939-2332
Practice Address - Country:US
Practice Address - Phone:540-932-4465
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101046891207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010373956Medicaid
VAP00401573OtherRR MEDICARE
VA006084443Medicaid
VA279744OtherBLUE SHIELD
VA279744OtherBLUE SHIELD
VAGC1100Medicare PIN
VA006084443Medicaid
VA110004038Medicare PIN
VA013284S22Medicare PIN