Provider Demographics
NPI:1174532014
Name:RUCKER, JAMES DANIEL (MD)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:DANIEL
Last Name:RUCKER
Suffix:
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:P.O. BOX 405827
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-5827
Mailing Address - Country:US
Mailing Address - Phone:870-934-5821
Mailing Address - Fax:870-934-5384
Practice Address - Street 1:5220 PARK AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38119-3500
Practice Address - Country:US
Practice Address - Phone:901-685-8245
Practice Address - Fax:901-685-8248
Is Sole Proprietor?:No
Enumeration Date:2006-08-07
Last Update Date:2011-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN10020207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4076564OtherBLUE CROSS BLUE SHIELD
TN4076564OtherBLUE CROSS BLUE SHIELD
B03555Medicare UPIN
TN103I089737Medicare PIN
TNB03555Medicare UPIN