Provider Demographics
NPI:1134106842
Name:RUCKMAN, RAYMOND JAMES (OD)
Entity Type:Individual
Prefix:DR
First Name:RAYMOND
Middle Name:JAMES
Last Name:RUCKMAN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 W TENTH ST
Mailing Address - Street 2:
Mailing Address - City:CARSON CITY
Mailing Address - State:NV
Mailing Address - Zip Code:89703-5201
Mailing Address - Country:US
Mailing Address - Phone:775-883-4664
Mailing Address - Fax:775-883-4750
Practice Address - Street 1:111 W TENTH ST
Practice Address - Street 2:
Practice Address - City:CARSON CITY
Practice Address - State:NV
Practice Address - Zip Code:89703-5201
Practice Address - Country:US
Practice Address - Phone:775-883-4664
Practice Address - Fax:775-883-4750
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-23
Last Update Date:2020-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV638152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVCH214XOtherMEDICARE PTAN
12019435OtherCAQH