Provider Demographics
NPI:1730184805
Name:TUCK, KENNETH D (MD)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:D
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:PO BOX 1789
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24008-1789
Mailing Address - Country:US
Mailing Address - Phone:540-855-5100
Mailing Address - Fax:
Practice Address - Street 1:3320 FRANKLIN RD SW
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24014-1310
Practice Address - Country:US
Practice Address - Phone:540-855-5100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2009-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101013638207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA006307248Medicaid
VA180037870Medicare PIN
VA180000812Medicare PIN
VAB07327Medicare UPIN