Provider Demographics
NPI:1265426738
Name:TUCKER, JEFFREY GLEN (MD)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:GLEN
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 1:980 SANDERS RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30041-5977
Mailing Address - Country:US
Mailing Address - Phone:770-886-1074
Mailing Address - Fax:770-205-4717
Practice Address - Street 1:980 SANDERS RD
Practice Address - Street 2:SUITE 100
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30041-5977
Practice Address - Country:US
Practice Address - Phone:770-886-1074
Practice Address - Fax:770-205-4717
Is Sole Proprietor?:No
Enumeration Date:2005-09-09
Last Update Date:2017-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA034068174400000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000468608KMedicaid
GA202I023240Medicare PIN
GAF43611Medicare UPIN
GA000468608KMedicaid