Provider Demographics
NPI:1861667982
Name:STUCKEN, CHARLTON E (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLTON
Middle Name:E
Last Name:STUCKEN
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 1:2828 S SEACREST BLVD
Mailing Address - Street 2:SUITE 216
Mailing Address - City:BOYNTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33435-7944
Mailing Address - Country:US
Mailing Address - Phone:561-395-2117
Mailing Address - Fax:
Practice Address - Street 1:1401 NW 9TH AVE
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33486-1304
Practice Address - Country:US
Practice Address - Phone:561-395-5733
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-29
Last Update Date:2013-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA233111207X00000X
FLME115536207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA233111Medicaid
MA233111Medicare PIN
FLH1554ZMedicare PIN
MA233111Medicare Oscar/Certification
MA233111Medicare UPIN