Provider Demographics
NPI:1053384107
Name:THOLE, ROBERT TUCKER (MD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:TUCKER
Last Name:THOLE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:850 HARVARD WAY
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89502-2055
Mailing Address - Country:US
Mailing Address - Phone:775-982-4590
Mailing Address - Fax:775-982-4595
Practice Address - Street 1:975 RYLAND ST STE 100
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89502
Practice Address - Country:US
Practice Address - Phone:775-982-5000
Practice Address - Fax:775-982-5225
Is Sole Proprietor?:No
Enumeration Date:2006-02-09
Last Update Date:2019-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV9686207QS0010X, 207Q00000X, 207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
11042017OtherCAQH
NV002016818Medicaid
NVP00259419OtherRR MEDICARE
NV080173706OtherRAILROAD MEDICARE
NVP00259419OtherRR MEDICARE
V100051Medicare PIN
11042017OtherCAQH