Provider Demographics
NPI:1962574806
Name:RUCKERT, GUSTAVE THEODORE (MD)
Entity type:Individual
Prefix:DR
First Name:GUSTAVE
Middle Name:THEODORE
Last Name:RUCKERT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:G. THEODORE
Other - Middle Name:
Other - Last Name:RUCKERT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:990 SOUTH AVE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14620-2740
Mailing Address - Country:US
Mailing Address - Phone:585-232-3210
Mailing Address - Fax:585-232-4657
Practice Address - Street 1:990 SOUTH AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14620-2740
Practice Address - Country:US
Practice Address - Phone:585-232-3210
Practice Address - Fax:585-232-4657
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY114643207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00471843Medicaid
NYF66855Medicare UPIN
NY37150DMedicare ID - Type UnspecifiedMEDICARE I.D. NUMBER