Provider Demographics
NPI:1356421366
Name:TUCKER, ANTHONY (MD)
Entity type:Individual
Prefix:
First Name:ANTHONY
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 1:1840 ELDRON BLVD SE STE 1
Mailing Address - Street 2:
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32909-6871
Mailing Address - Country:US
Mailing Address - Phone:321-312-4580
Mailing Address - Fax:321-914-4053
Practice Address - Street 1:1840 ELDRON BLVD SE STE 1
Practice Address - Street 2:
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32909-6871
Practice Address - Country:US
Practice Address - Phone:321-312-4580
Practice Address - Fax:321-914-4053
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2018-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY171620207P00000X
FLME120268207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02585871Medicaid
NY02585871Medicaid
NYF17736Medicare UPIN