Provider Demographics
NPI:1780677054
Name:TUCKER, BRUCE NICHOLSON (MD)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:NICHOLSON
Last Name:TUCKER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3536 MENDOCINO AVE
Mailing Address - Street 2:STE 200
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95403-3634
Mailing Address - Country:US
Mailing Address - Phone:707-575-6049
Mailing Address - Fax:707-544-0834
Practice Address - Street 1:3536 MENDOCINO AVE
Practice Address - Street 2:STE 300
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403-3634
Practice Address - Country:US
Practice Address - Phone:707-544-3411
Practice Address - Fax:707-544-0834
Is Sole Proprietor?:No
Enumeration Date:2005-08-23
Last Update Date:2012-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG44233207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
00G442330OtherBLUE SHIELD OF CALIFORNIA
CA00G442330Medicaid
CAP00420858OtherRAILROAD MEDICARE
CAP00420858OtherRAILROAD MEDICARE
CA00G442330Medicaid
CAEB548ZMedicare PIN
A49590Medicare UPIN