Provider Demographics
NPI:1396599106
Name:TUCK, TRAVIS (DO)
Entity type:Individual
Prefix:
First Name:TRAVIS
Middle Name:
Last Name:TUCK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 ABBEY RD
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:NM
Mailing Address - Zip Code:88101-8042
Mailing Address - Country:US
Mailing Address - Phone:850-559-6621
Mailing Address - Fax:
Practice Address - Street 1:224 WEST D.L. INGRAM AVE
Practice Address - Street 2:BLDG. 1408
Practice Address - City:APO
Practice Address - State:AA
Practice Address - Zip Code:88103
Practice Address - Country:US
Practice Address - Phone:575-784-2778
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-16
Last Update Date:2025-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34.018179171000000X
OH58.034243390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171000000XOther Service ProvidersMilitary Health Care Provider
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program