Provider Demographics
NPI:1255435525
Name:RUCKER, BENJAMIN LAVAR JR (MD)
Entity type:Individual
Prefix:MR
First Name:BENJAMIN
Middle Name:LAVAR
Last Name:RUCKER
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 1:1448 LEE BEARD WAY
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30901-3414
Mailing Address - Country:US
Mailing Address - Phone:706-828-7468
Mailing Address - Fax:706-724-7566
Practice Address - Street 1:1448 LEE BEARD WAY
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30901-3414
Practice Address - Country:US
Practice Address - Phone:706-828-7468
Practice Address - Fax:706-724-7566
Is Sole Proprietor?:No
Enumeration Date:2006-09-08
Last Update Date:2011-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA017877207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
581476757OtherCOMMERCIAL
GA000153139-BMedicaid
0400527OtherUNITED HEALTHCARE
G17877OtherSC MEDICAID
010270OtherBCBS
581476757OtherCHAMPUS
G17877OtherSC MEDICAID