Provider Demographics
NPI:1952354151
Name:TUCKER, NEIL THOMAS (MD)
Entity Type:Individual
Prefix:
First Name:NEIL
Middle Name:THOMAS
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 1:1700 NW 49TH ST STE 125
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33309-3750
Mailing Address - Country:US
Mailing Address - Phone:954-832-0332
Mailing Address - Fax:954-832-0289
Practice Address - Street 1:1625 SE 3RD AVE STE 200
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33316-2521
Practice Address - Country:US
Practice Address - Phone:954-832-0332
Practice Address - Fax:954-832-0289
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2019-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME00601942080P0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0206XAllopathic & Osteopathic PhysiciansPediatricsPediatric Gastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL273540700Medicaid
FL29491YMedicare PIN
FL273540700Medicaid