Provider Demographics
NPI:1972765592
Name:TUCKER, JOHN J II (DO)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:J
Last Name:TUCKER
Suffix:II
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4672 N SONOMA RANCH BLVD STE B
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88011-7271
Mailing Address - Country:US
Mailing Address - Phone:575-556-1871
Mailing Address - Fax:575-556-1872
Practice Address - Street 1:4672 N SONOMA RANCH BLVD STE B
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011-7271
Practice Address - Country:US
Practice Address - Phone:575-556-1871
Practice Address - Fax:575-556-1872
Is Sole Proprietor?:No
Enumeration Date:2008-06-25
Last Update Date:2018-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVSL0564390200000X
NMA-1633-11207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM22909311Medicaid
NM22909311Medicaid