Provider Demographics
NPI:1750987079
Name:TUCKER, BOBBY JOE
Entity type:Individual
Prefix:
First Name:BOBBY
Middle Name:JOE
Last Name:TUCKER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:712 PALMER AVE
Mailing Address - Street 2:
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44502-2531
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6315 PEARL RD STE 206
Practice Address - Street 2:
Practice Address - City:PARMA HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44130-3074
Practice Address - Country:US
Practice Address - Phone:440-613-5222
Practice Address - Fax:440-613-5222
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-10
Last Update Date:2020-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332H00000X
OHOP.017156-S156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
No332H00000XSuppliersEyewear Supplier