Provider Demographics
NPI:1508890856
Name:STUCKER, FREDERICK J JR (MD)
Entity Type:Individual
Prefix:
First Name:FREDERICK
Middle Name:J
Last Name:STUCKER
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1501 KINGS HWY
Mailing Address - Street 2:DEPARTMENT OF OTOLARYNGOLOGY
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71103-4228
Mailing Address - Country:US
Mailing Address - Phone:318-813-2690
Mailing Address - Fax:318-813-2692
Practice Address - Street 1:1501 KINGS HWY
Practice Address - Street 2:DEPARTMENT OF OTOLARYNGOLOGY
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71103-4228
Practice Address - Country:US
Practice Address - Phone:318-813-2690
Practice Address - Fax:318-813-2692
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2009-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA05832R207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1320927Medicaid
LAB89080Medicare UPIN
LA1320927Medicaid