Basic Information
| Provider Information | |||||||||
| NPI: | 1831394675 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RUCKNAGEL | ||||||||
| FirstName: | DONALD | ||||||||
| MiddleName: | LOUIS | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2830 VICTORY PKWY | ||||||||
| Address2: | CENTRAL CREDENTIALING | ||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452061785 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5132453669 | ||||||||
| FaxNumber: | 5134757259 | ||||||||
| Practice Location | |||||||||
| Address1: | 234 GOODMAN ST | ||||||||
| Address2: | BARRETT CENTER | ||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452192364 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5135846928 | ||||||||
| FaxNumber: | 5135844281 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2007 | ||||||||
| LastUpdateDate: | 10/25/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 35056118 | OH | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207SG0201X | 35056118 | OH | Y | Allopathic & Osteopathic Physicians | Medical Genetics | Clinical Genetics (M.D.) |
ID Information
| ID | Type | State | Issuer | Description | 0372341 | 05 | OH | MEDICAID | 200012580 | 05 | IN | MEDICAID | 6486453100 | 05 | KY | MEDICAID |