Provider Demographics
NPI:1023155561
Name:DUCKER, STACI WYNN (OD)
Entity type:Individual
Prefix:
First Name:STACI
Middle Name:WYNN
Last Name:DUCKER
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 1:1620 W OAK KNOLL CIR
Mailing Address - Street 2:
Mailing Address - City:DAVIE
Mailing Address - State:FL
Mailing Address - Zip Code:33324-6411
Mailing Address - Country:US
Mailing Address - Phone:954-540-2558
Mailing Address - Fax:
Practice Address - Street 1:185 MILWAUKEE AVE STE 135
Practice Address - Street 2:
Practice Address - City:LINCOLNSHIRE
Practice Address - State:IL
Practice Address - Zip Code:60069-3038
Practice Address - Country:US
Practice Address - Phone:847-325-4440
Practice Address - Fax:847-325-4443
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-01
Last Update Date:2017-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046011065152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL621057100Medicaid