Basic Information
| Provider Information | |||||||||
| NPI: | 1720024425 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TUCKER | ||||||||
| FirstName: | DALE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 863026 | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328863026 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043465426 | ||||||||
| FaxNumber: | 9043460113 | ||||||||
| Practice Location | |||||||||
| Address1: | 10503 SAN JOSE BLVD | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322576295 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9044506700 | ||||||||
| FaxNumber: | 9044506691 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2006 | ||||||||
| LastUpdateDate: | 10/19/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | ME0076518 | FL | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207Q00000X | ME76518 | FL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 35915 | 01 | FL | BCBS | OTHER | 261605000 | 05 | FL | MEDICAID | 930119999 | 01 | FL | RAILROAD MEDICARE | OTHER |