Provider Demographics
NPI:1356344527
Name:TULECKE, MARK A (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:TULECKE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:MARK
Other - Middle Name:A
Other - Last Name:TULECKE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 100519
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-0519
Mailing Address - Country:US
Mailing Address - Phone:888-208-6228
Mailing Address - Fax:603-778-1602
Practice Address - Street 1:1 HAMPTON RD
Practice Address - Street 2:UNIT 208
Practice Address - City:EXETER
Practice Address - State:NH
Practice Address - Zip Code:03833-4849
Practice Address - Country:US
Practice Address - Phone:603-778-8522
Practice Address - Fax:603-778-1602
Is Sole Proprietor?:No
Enumeration Date:2005-05-23
Last Update Date:2008-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH11886207ZC0500X, 207ZP0102X
MA155848207ZC0500X, 207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No207ZC0500XAllopathic & Osteopathic PhysiciansPathologyCytopathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAJ23428OtherBCBS MA
MA133442Medicaid
NH01Y004638NH01OtherBCBS NH
NH30203467Medicaid
NH30203467Medicaid
H38623Medicare UPIN
NHTURE7112Medicare ID - Type Unspecified
NHRE7112Medicare Oscar/Certification