Provider Demographics
NPI:1811575236
Name:STUCKER, KYLE MATTHEW (MD)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:MATTHEW
Last Name:STUCKER
Suffix:
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:PO BOX 776351
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6351
Mailing Address - Country:US
Mailing Address - Phone:502-559-9407
Mailing Address - Fax:502-272-5339
Practice Address - Street 1:1 AUDUBON PLAZA DR
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40217-1318
Practice Address - Country:US
Practice Address - Phone:502-636-7225
Practice Address - Fax:502-636-8032
Is Sole Proprietor?:No
Enumeration Date:2021-03-29
Last Update Date:2024-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY58468208D00000X, 207P00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program