Provider Demographics
NPI:1790861409
Name:TUCKER, WILLIAM MARTIN III (MD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:MARTIN
Last Name:TUCKER
Suffix:III
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:PO BOX 530062
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30353-0062
Mailing Address - Country:US
Mailing Address - Phone:843-695-6071
Mailing Address - Fax:843-569-5879
Practice Address - Street 1:119 SPRINGHALL DR
Practice Address - Street 2:
Practice Address - City:GOOSE CREEK
Practice Address - State:SC
Practice Address - Zip Code:29445-5368
Practice Address - Country:US
Practice Address - Phone:843-266-2520
Practice Address - Fax:843-553-4436
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2021-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC26336207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC263360Medicaid
SCAA18307126Medicare PIN
SC263360Medicaid
SCP00397291Medicare PIN
SCI73580Medicare UPIN