Provider Demographics
NPI:1245279892
Name:TUCKER, STEPHEN B (MD)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:B
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 1:1055 EVERGREEN CIR
Mailing Address - Street 2:
Mailing Address - City:THE WOODLANDS
Mailing Address - State:TX
Mailing Address - Zip Code:77380-3602
Mailing Address - Country:US
Mailing Address - Phone:281-367-9110
Mailing Address - Fax:832-813-0344
Practice Address - Street 1:1055 EVERGREEN CIR
Practice Address - Street 2:
Practice Address - City:THE WOODLANDS
Practice Address - State:TX
Practice Address - Zip Code:77380-3602
Practice Address - Country:US
Practice Address - Phone:281-367-9110
Practice Address - Fax:832-813-0344
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2022-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF6143207N00000X, 207ND0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX178810101Medicaid
TXDE5715OtherRAILROAD GROUP
TX87X447OtherBCBSTX
TX070002920OtherRAILROAD
TXTXB122920OtherPTAN
TXTXB122920OtherPTAN
TX00929YMedicare PIN
TX8D7380Medicare PIN
TX00EU29Medicare PIN