Provider Demographics
NPI:1841232691
Name:TUCKER, MICHAEL MATTHEWS (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:MATTHEWS
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:PO BOX 370
Mailing Address - Street 2:
Mailing Address - City:FORTSON
Mailing Address - State:GA
Mailing Address - Zip Code:31808-0370
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:706-494-3008
Practice Address - Street 1:6262 VETERANS PKWY
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31909-3540
Practice Address - Country:US
Practice Address - Phone:706-324-6661
Practice Address - Fax:706-494-3201
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2020-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALMD.28249207XX0005X
GA57695207XX0005X
GA057695207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
I52860Medicare UPIN
AL510I200016Medicare PIN
GA20NCCNDMedicare PIN