Provider Demographics
NPI:1831182302
Name:DISALVO-TUCKMAN, MARIA (MD)
Entity type:Individual
Prefix:
First Name:MARIA
Middle Name:
Last Name:DISALVO-TUCKMAN
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:PO BOX 13579
Mailing Address - Street 2:
Mailing Address - City:READING
Mailing Address - State:PA
Mailing Address - Zip Code:19612-3579
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:301 S 7TH AVE
Practice Address - Street 2:SUITE 3170
Practice Address - City:WEST READING
Practice Address - State:PA
Practice Address - Zip Code:19611-1410
Practice Address - Country:US
Practice Address - Phone:610-898-9380
Practice Address - Fax:610-478-1170
Is Sole Proprietor?:No
Enumeration Date:2005-08-30
Last Update Date:2014-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD050290L208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001464416Medicaid
PA193142Medicare PIN
PA001464416Medicaid