Basic Information
| Provider Information | |||||||||
| NPI: | 1578664462 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TUCKER | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | MARY | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 ESSEX CENTER DRIVE | ||||||||
| Address2: | LAHEY CLINIC | ||||||||
| City: | PEABODY | ||||||||
| State: | MA | ||||||||
| PostalCode: | 019602901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9785384400 | ||||||||
| FaxNumber: | 9785384724 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 ESSEX CENTER DR | ||||||||
| Address2: | LAHEY CLINIC | ||||||||
| City: | PEABODY | ||||||||
| State: | MA | ||||||||
| PostalCode: | 019602901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9785384400 | ||||||||
| FaxNumber: | 9785384724 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/26/2006 | ||||||||
| LastUpdateDate: | 05/04/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | 156646 | MA | N | Allopathic & Osteopathic Physicians | Ophthalmology | 207WX0200X | 156646 | MA | Y |
ID Information
| ID | Type | State | Issuer | Description | 110059835A | 05 | MA | MEDICAID |