Provider Demographics
NPI:1902882400
Name:TUCK, RICHARD (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:
Last Name:TUCK
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 1:859 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MALTA
Mailing Address - State:OH
Mailing Address - Zip Code:43758-9007
Mailing Address - Country:US
Mailing Address - Phone:740-961-6111
Mailing Address - Fax:740-962-2182
Practice Address - Street 1:859 N MAIN ST
Practice Address - Street 2:
Practice Address - City:MALTA
Practice Address - State:OH
Practice Address - Zip Code:43758-9007
Practice Address - Country:US
Practice Address - Phone:740-961-6111
Practice Address - Fax:740-962-2182
Is Sole Proprietor?:No
Enumeration Date:2005-12-16
Last Update Date:2012-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35041985T208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000018866OtherANTHEM PIN
OH000000177522OtherUNISON PIN
OHCA0426OtherGROUP MEDICARE
OH0379906Medicaid
OH1293242OtherUHC PIN
OH311413469035OtherCARESOURCE PIN
OHTU0770182Medicare ID - Type Unspecified
OH000000177522OtherUNISON PIN
9270904Medicare PIN