Provider Demographics
NPI:1023087012
Name:TUCKER, GLADSTONE A (MD)
Entity type:Individual
Prefix:DR
First Name:GLADSTONE
Middle Name:A
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 752
Mailing Address - Street 2:
Mailing Address - City:CONCORDIA
Mailing Address - State:MO
Mailing Address - Zip Code:64020-0752
Mailing Address - Country:US
Mailing Address - Phone:660-463-1365
Mailing Address - Fax:660-463-1367
Practice Address - Street 1:1606 CASTLEBERRY DR
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IL
Practice Address - Zip Code:62959-1586
Practice Address - Country:US
Practice Address - Phone:618-997-9519
Practice Address - Fax:618-993-0592
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2023-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036111926208M00000X, 207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL252364OtherHARMONY
IL036111926Medicaid
IL07332006OtherBCBS
IL229260OtherCOVENTRY
ILP00239844OtherMEDICARE - RAILROAD
IL699628OtherHEALTHLINK
IL9367182OtherCIGNA
ILP00239844OtherMEDICARE - RAILROAD
IL699628OtherHEALTHLINK
IL229260OtherCOVENTRY