Provider Demographics
NPI:1295734226
Name:TUCKER, FORREST LEE (MD)
Entity type:Individual
Prefix:DR
First Name:FORREST
Middle Name:LEE
Last Name:TUCKER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:101 ELM AVE SE
Mailing Address - Street 2:ADMINISTRATIVE SUITE
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24013-2222
Mailing Address - Country:US
Mailing Address - Phone:540-985-8592
Mailing Address - Fax:540-985-0475
Practice Address - Street 1:101 ELM AVE SE
Practice Address - Street 2:ADMINISTRATIVE SUITE
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24013-2222
Practice Address - Country:US
Practice Address - Phone:540-985-8592
Practice Address - Fax:540-985-0475
Is Sole Proprietor?:No
Enumeration Date:2005-07-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101035168207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV6600061000Medicaid
WV6600061000Medicaid