Provider Demographics
NPI:1467574541
Name:USTRUCK, RACHAEL ELIZABETH (DO)
Entity Type:Individual
Prefix:DR
First Name:RACHAEL
Middle Name:ELIZABETH
Last Name:USTRUCK
Suffix:
Gender:F
Credentials:DO
Other - Prefix:DR
Other - First Name:RACHAEL
Other - Middle Name:ELIZABETH
Other - Last Name:KOKKINOS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:1200 W 12 MILE RD
Mailing Address - Street 2:
Mailing Address - City:MADISON HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48071-4439
Mailing Address - Country:US
Mailing Address - Phone:248-543-0600
Mailing Address - Fax:248-543-4720
Practice Address - Street 1:1200 W 12 MILE RD
Practice Address - Street 2:
Practice Address - City:MADISON HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48071-4439
Practice Address - Country:US
Practice Address - Phone:248-543-0600
Practice Address - Fax:248-543-4720
Is Sole Proprietor?:No
Enumeration Date:2007-04-06
Last Update Date:2012-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101017009207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1467574541Medicaid