Healthcare Provider Details

I. General information

NPI: 1396740445
Provider Name (Legal Business Name): ROBERT STUCKERT III D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2005
Last Update Date: 08/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

531 5TH ST
BEVERLY OH
45715-8916
US

IV. Provider business mailing address

PO BOX 325
BEVERLY OH
45715-0325
US

V. Phone/Fax

Practice location:
  • Phone: 740-984-1414
  • Fax: 740-984-1723
Mailing address:
  • Phone: 740-984-1414
  • Fax: 740-984-1723

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number34006102S
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: