Provider Demographics
NPI:1831184381
Name:TUCKERMAN, MYRA BETH (MD)
Entity type:Individual
Prefix:
First Name:MYRA
Middle Name:BETH
Last Name:TUCKERMAN
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 1:1790 30TH ST.
Mailing Address - Street 2:SUITE 308
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80301
Mailing Address - Country:US
Mailing Address - Phone:303-440-0205
Mailing Address - Fax:303-440-0209
Practice Address - Street 1:1790 30TH ST
Practice Address - Street 2:SUITE 308
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80301-1022
Practice Address - Country:US
Practice Address - Phone:303-440-0205
Practice Address - Fax:303-440-0209
Is Sole Proprietor?:No
Enumeration Date:2005-09-12
Last Update Date:2008-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO45139207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0191671Medicaid
080188923OtherRAILROAD MEDICARE
0790791Medicare PIN
C98191Medicare UPIN