Basic Information
| Provider Information | |||||||||
| NPI: | 1467611806 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TUCKER | ||||||||
| FirstName: | DOUGLAS | ||||||||
| MiddleName: | ARTHUR | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O., M.S. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 214 E 23RD ST | ||||||||
| Address2: | |||||||||
| City: | CHEYENNE | ||||||||
| State: | WY | ||||||||
| PostalCode: | 820013748 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3076342273 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 214 E 23RD ST | ||||||||
| Address2: | |||||||||
| City: | CHEYENNE | ||||||||
| State: | WY | ||||||||
| PostalCode: | 820013748 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3076342273 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2008 | ||||||||
| LastUpdateDate: | 07/04/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | TL-2829 | CO | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | DR.0048616 | CO | N | Allopathic & Osteopathic Physicians | Family Medicine | 208M00000X | 10191A | WY | N | Allopathic & Osteopathic Physicians | Hospitalist | 207Q00000X | 10191A | WY | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 87672588 | 05 | CO | MEDICAID |