Provider Demographics
NPI:1649473919
Name:TUCKER, MELISSA WILSON (MD)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:WILSON
Last Name:TUCKER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3680 SANGANI BLVD
Mailing Address - Street 2:
Mailing Address - City:DIBERVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39540-8703
Mailing Address - Country:US
Mailing Address - Phone:228-354-9300
Mailing Address - Fax:228-354-9301
Practice Address - Street 1:3680 SANGANI BLVD
Practice Address - Street 2:
Practice Address - City:DIBERVILLE
Practice Address - State:MS
Practice Address - Zip Code:39540-8703
Practice Address - Country:US
Practice Address - Phone:228-354-9300
Practice Address - Fax:228-354-9301
Is Sole Proprietor?:No
Enumeration Date:2007-06-06
Last Update Date:2014-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS22560207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine