Provider Demographics
NPI:1841234408
Name:BIERBAUM, TUCKER (MD)
Entity Type:Individual
Prefix:
First Name:TUCKER
Middle Name:
Last Name:BIERBAUM
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 1:1165 MONTGOMERY DR
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95405-4801
Mailing Address - Country:US
Mailing Address - Phone:800-617-7717
Mailing Address - Fax:
Practice Address - Street 1:1165 MONTGOMERY DR
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95405-4801
Practice Address - Country:US
Practice Address - Phone:800-617-7717
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-15
Last Update Date:2007-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG54985207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA52841Medicare UPIN
CA00G549850Medicare ID - Type Unspecified