Provider Demographics
NPI:1780764290
Name:TUCKER, GEORGE SEAN (MD)
Entity type:Individual
Prefix:
First Name:GEORGE
Middle Name:SEAN
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 1:965 RIDGE LAKE BLVD STE 103
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38120-9446
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:901-227-8591
Practice Address - Street 1:401 SOUTHCREST CIR STE 104
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-6712
Practice Address - Country:US
Practice Address - Phone:662-349-1112
Practice Address - Fax:662-772-2688
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2020-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAGA-055033207V00000X
MS22162207V00000X
TN47823207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA936743017HMedicaid
GA936743017IMedicaid
GA936743017JMedicaid
GA936743017KMedicaid
GA936743017AMedicaid
GA936743017HMedicaid
GA936743017KMedicaid