Provider Demographics
NPI:1831204478
Name:TUCKER, CHARLES THOMAS (MD)
Entity type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:THOMAS
Last Name:TUCKER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:208 SCRANTON CONNECTOR
Mailing Address - Street 2:SUITE 117
Mailing Address - City:BRUNSWICK
Mailing Address - State:GA
Mailing Address - Zip Code:31525-0559
Mailing Address - Country:US
Mailing Address - Phone:912-264-5961
Mailing Address - Fax:912-262-9499
Practice Address - Street 1:111 COLONIAL WAY STE 2
Practice Address - Street 2:
Practice Address - City:JESUP
Practice Address - State:GA
Practice Address - Zip Code:31545-0132
Practice Address - Country:US
Practice Address - Phone:912-588-1919
Practice Address - Fax:912-588-1919
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-21
Last Update Date:2020-01-16
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
GA026402207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA01035667OtherAMERIGROUP
GA390004393OtherRAILROAD MEDICARE
GA616370OtherBLUE SHIELD
GA000291079AMedicaid
GAN363398OtherWELLCARE
GA000291079AMedicaid
GAE01061Medicare UPIN
GAN363398OtherWELLCARE