Provider Demographics
NPI:1003607839
Name:RUCKER, WILLIAM TRAVIS SR
Entity type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:TRAVIS
Last Name:RUCKER
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5525 GREENFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-7113
Mailing Address - Country:US
Mailing Address - Phone:317-868-6944
Mailing Address - Fax:317-868-6944
Practice Address - Street 1:5525 GREENFIELD AVE
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46219-7113
Practice Address - Country:US
Practice Address - Phone:317-868-6944
Practice Address - Fax:317-868-6944
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-13
Last Update Date:2025-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist