Provider Demographics
NPI:1750340808
Name:RUCKER, RICHARD DOUGLAS JR (MD PHD)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:DOUGLAS
Last Name:RUCKER
Suffix:JR
Gender:M
Credentials:MD PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:795 MIDDLE ST
Mailing Address - Street 2:
Mailing Address - City:FALL RIVER
Mailing Address - State:MA
Mailing Address - Zip Code:02721-1733
Mailing Address - Country:US
Mailing Address - Phone:508-674-5600
Mailing Address - Fax:508-675-5611
Practice Address - Street 1:795 MIDDLE ST
Practice Address - Street 2:
Practice Address - City:FALL RIVER
Practice Address - State:MA
Practice Address - Zip Code:02721-1733
Practice Address - Country:US
Practice Address - Phone:508-674-5600
Practice Address - Fax:508-675-5611
Is Sole Proprietor?:No
Enumeration Date:2006-03-18
Last Update Date:2013-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN23186207P00000X
MA58164207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA58164OtherMASSACHUSETTS LICENSE
23186OtherMN MEDICAL LICENSE
MN993565700Medicaid
930000591Medicare ID - Type Unspecified
MN993565700Medicaid