Provider Demographics
NPI:1205983012
Name:STUCKEY, JORDAN W (MD)
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:W
Last Name:STUCKEY
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 1:1200 RALSTON AVE
Mailing Address - Street 2:DEPARTMENT OF SURGERY
Mailing Address - City:DEFIANCE
Mailing Address - State:OH
Mailing Address - Zip Code:43512-1396
Mailing Address - Country:US
Mailing Address - Phone:419-783-6944
Mailing Address - Fax:419-783-4416
Practice Address - Street 1:1200 RALSTON AVE
Practice Address - Street 2:DEPARTMENT OF SURGERY
Practice Address - City:DEFIANCE
Practice Address - State:OH
Practice Address - Zip Code:43512-1396
Practice Address - Country:US
Practice Address - Phone:419-783-6944
Practice Address - Fax:419-783-4416
Is Sole Proprietor?:No
Enumeration Date:2007-01-04
Last Update Date:2023-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35094500207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH97054449OtherAETNA
OHP00812723OtherRRMC
OH000000637364OtherANTHEM
OH2994014Medicaid
OH2994014Medicaid