Provider Demographics
NPI:1750743050
Name:RUECKERT, JUSTIN ADAM (DO)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:ADAM
Last Name:RUECKERT
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6708 PENNS CHAPEL RD
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42101-7000
Mailing Address - Country:US
Mailing Address - Phone:801-707-6354
Mailing Address - Fax:
Practice Address - Street 1:800 ROSE ST
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40536-2200
Practice Address - Country:US
Practice Address - Phone:859-257-1446
Practice Address - Fax:859-257-7572
Is Sole Proprietor?:No
Enumeration Date:2016-03-25
Last Update Date:2022-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY04988207ZF0201X, 207ZP0102X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No207ZF0201XAllopathic & Osteopathic PhysiciansPathologyForensic Pathology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program