Provider Demographics
NPI:1114361003
Name:STUCKEY, RANDALL MARK JR (DO)
Entity Type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:MARK
Last Name:STUCKEY
Suffix:JR
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 CENTURY AVE SE
Mailing Address - Street 2:
Mailing Address - City:HUTCHINSON
Mailing Address - State:MN
Mailing Address - Zip Code:55350-3108
Mailing Address - Country:US
Mailing Address - Phone:320-234-3290
Mailing Address - Fax:
Practice Address - Street 1:3 CENTURY AVE SE
Practice Address - Street 2:
Practice Address - City:HUTCHINSON
Practice Address - State:MN
Practice Address - Zip Code:55350-3108
Practice Address - Country:US
Practice Address - Phone:320-234-3290
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-22
Last Update Date:2016-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MN58231207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program