Provider Demographics
NPI:1871905018
Name:TUCKER, HEIDI MARIE (DO)
Entity type:Individual
Prefix:
First Name:HEIDI
Middle Name:MARIE
Last Name:TUCKER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 MANSFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:WILLIMANTIC
Mailing Address - State:CT
Mailing Address - Zip Code:06226-2018
Mailing Address - Country:US
Mailing Address - Phone:860-963-7916
Mailing Address - Fax:
Practice Address - Street 1:202 POMFRET ST
Practice Address - Street 2:
Practice Address - City:PUTNAM
Practice Address - State:CT
Practice Address - Zip Code:06260
Practice Address - Country:US
Practice Address - Phone:860-963-7917
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-22
Last Update Date:2019-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA271687207Q00000X
CT63797207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine