Healthcare Provider Details

I. General information

NPI: 1588669535
Provider Name (Legal Business Name): WARREN J. STUCKI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2005
Last Update Date: 04/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

736 S 900 E STE 108
ST GEORGE UT
84790-7002
US

IV. Provider business mailing address

736 S 900 E STE 108
ST GEORGE UT
84790-7002
US

V. Phone/Fax

Practice location:
  • Phone: 435-628-3606
  • Fax: 435-628-8404
Mailing address:
  • Phone: 435-628-3606
  • Fax: 435-628-8404

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number158544-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: