Provider Demographics
NPI:1134106883
Name:RUCKER, GARY W (DO)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:W
Last Name:RUCKER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Mailing Address - Street 1:1165 E CHERRY ST
Mailing Address - Street 2:PO BOX 312
Mailing Address - City:TROY
Mailing Address - State:MO
Mailing Address - Zip Code:63379-1520
Mailing Address - Country:US
Mailing Address - Phone:636-528-7722
Mailing Address - Fax:636-528-7744
Practice Address - Street 1:1165 E CHERRY ST
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MO
Practice Address - Zip Code:63379-1520
Practice Address - Country:US
Practice Address - Phone:636-528-7722
Practice Address - Fax:636-528-7744
Is Sole Proprietor?:No
Enumeration Date:2005-12-23
Last Update Date:2013-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR6346207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO247744709Medicaid
MOE25936Medicare UPIN
MO000003120Medicare Oscar/Certification