Provider Demographics
NPI:1831187269
Name:TUCKER, THEODORE C (MD)
Entity type:Individual
Prefix:
First Name:THEODORE
Middle Name:C
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 1:825 22ND ST
Mailing Address - Street 2:
Mailing Address - City:FAIRBURY
Mailing Address - State:NE
Mailing Address - Zip Code:68352-1221
Mailing Address - Country:US
Mailing Address - Phone:402-729-3361
Mailing Address - Fax:
Practice Address - Street 1:825 22ND ST
Practice Address - Street 2:
Practice Address - City:FAIRBURY
Practice Address - State:NE
Practice Address - Zip Code:68352-1221
Practice Address - Country:US
Practice Address - Phone:402-729-3361
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-10
Last Update Date:2016-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE21919207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200305540AMedicaid
H52818Medicare UPIN