Provider Demographics
NPI:1821091620
Name:TUCKMAN, GLENN A (MD)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:A
Last Name:TUCKMAN
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 1:6416 SHAMEL DR
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46278-1170
Mailing Address - Country:US
Mailing Address - Phone:317-876-1229
Mailing Address - Fax:
Practice Address - Street 1:3738 LANDMARK DR
Practice Address - Street 2:STE D
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47905-6654
Practice Address - Country:US
Practice Address - Phone:765-449-7984
Practice Address - Fax:765-449-9791
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-24
Last Update Date:2020-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAMD-405392085B0100X, 2085R0202X
IN01039553A2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody Imaging
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200020370BMedicaid
KY64882822Medicaid
IN200020370BMedicaid
KY64882822Medicaid
ININ1405001Medicare PIN