Provider Demographics
NPI:1558498543
Name:STUCKEY, KIMBERLY N (OD)
Entity type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:N
Last Name:STUCKEY
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5335 HENDRON RD
Mailing Address - Street 2:
Mailing Address - City:GROVEPORT
Mailing Address - State:OH
Mailing Address - Zip Code:43125-1055
Mailing Address - Country:US
Mailing Address - Phone:614-836-9669
Mailing Address - Fax:614-836-9703
Practice Address - Street 1:5335 HENDRON RD
Practice Address - Street 2:
Practice Address - City:GROVEPORT
Practice Address - State:OH
Practice Address - Zip Code:43125-1055
Practice Address - Country:US
Practice Address - Phone:614-836-9669
Practice Address - Fax:614-836-9703
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-27
Last Update Date:2014-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5682152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0073144Medicaid
OH0073144Medicaid