Provider Demographics
NPI:1770601874
Name:WAYNE TUCKER DO, PA
Entity type:Organization
Organization Name:WAYNE TUCKER DO, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WAYNE
Authorized Official - Middle Name:IRA
Authorized Official - Last Name:TUCKER
Authorized Official - Suffix:
Authorized Official - Credentials:DO, PA
Authorized Official - Phone:302-838-1100
Mailing Address - Street 1:101 BECKS WOODS DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:BEAR
Mailing Address - State:DE
Mailing Address - Zip Code:19701
Mailing Address - Country:US
Mailing Address - Phone:302-838-1100
Mailing Address - Fax:302-838-8962
Practice Address - Street 1:100 BECKS WOODS DR
Practice Address - Street 2:SUITE 202
Practice Address - City:BEAR
Practice Address - State:DE
Practice Address - Zip Code:19701-3835
Practice Address - Country:US
Practice Address - Phone:302-838-1100
Practice Address - Fax:302-838-8962
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-27
Last Update Date:2014-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEF1-0000484111N00000X
DEC2004133207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE0001131503Medicaid
DE0100579OtherUNITED HEALTHCARE
DE1770601874OtherBCBS
DE116893OtherCOVENTRY
DE4331251OtherAETNA
DEG00654Medicare PIN