Provider Demographics
NPI:1922039023
Name:TUCKSON, WAYNE (MD)
Entity Type:Individual
Prefix:
First Name:WAYNE
Middle Name:
Last Name:TUCKSON
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 1:6801 DIXIE HWY
Mailing Address - Street 2:STE 130
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40258-3913
Mailing Address - Country:US
Mailing Address - Phone:502-583-8005
Mailing Address - Fax:502-583-8025
Practice Address - Street 1:3920 DUTCHMANS LN STE 315
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4702
Practice Address - Country:US
Practice Address - Phone:502-583-8005
Practice Address - Fax:502-583-8025
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2019-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY30849208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64308497Medicaid
IN100373940Medicaid
IN100373940Medicaid
KYP00605796Medicare PIN