Basic Information
| Provider Information | |||||||||
| NPI: | 1598788507 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BUCKNER | ||||||||
| FirstName: | VICTORIA | ||||||||
| MiddleName: | RUTH | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 6661 CLYO RD | ||||||||
| Address2: | |||||||||
| City: | CENTERVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454592702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9374254000 | ||||||||
| FaxNumber: | 9374254002 | ||||||||
| Practice Location | |||||||||
| Address1: | 2115 LEITER RD | ||||||||
| Address2: | SYCAMORE PRIMARY CARE GROUP | ||||||||
| City: | MIAMISBURG | ||||||||
| State: | OH | ||||||||
| PostalCode: | 453423659 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9373846800 | ||||||||
| FaxNumber: | 9373846939 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/25/2006 | ||||||||
| LastUpdateDate: | 01/28/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 2006-01029 | NC | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 34009103 | OH | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 190798 | 01 | NC | MEDCOST | OTHER | 808057 | 01 | NC | PARTNERS MEDICARE CH | OTHER | 7345780 | 01 | AETNA | OTHER | 190798 | 01 | NC | MEDCOST ID | OTHER | 14214 | 01 | NC | BCBS ID | OTHER | P00328842 | 01 | NC | RAILROAD MEDICARE ID | OTHER | 14214 | 01 | NC | BCBSNC | OTHER | 2767439 | 05 | OH | MEDICAID | 5904460 | 05 | NC | MEDICAID | 566000156 | 01 | NC | PRATICE TAX ID | OTHER | 7345780 | 01 | NC | AETNA ID | OTHER | 808057 | 01 | NC | PARTNERS MEDICARE CHOICE | OTHER | BB9846619 | 01 | NC | DEA | OTHER | 311446216 | 01 | OH | PRACTICE TAX ID # | OTHER |