Provider Demographics
NPI:1336226018
Name:TUCKER, ALLEN (MD)
Entity Type:Individual
Prefix:DR
First Name:ALLEN
Middle Name:
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 1:1830 E BROAD ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43203-2003
Mailing Address - Country:US
Mailing Address - Phone:614-252-2211
Mailing Address - Fax:614-252-4011
Practice Address - Street 1:1830 EAST BROAD STREET
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43203-2003
Practice Address - Country:US
Practice Address - Phone:614-252-2211
Practice Address - Fax:614-252-4011
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-04-4012-T207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0427872Medicaid
OH0427872Medicaid
OH36D0328791Medicare ID - Type Unspecified