Basic Information
| Provider Information | |||||||||
| NPI: | 1609849264 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BUCK | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | P | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3170 KETTERING BLVD BLDG B3 | ||||||||
| Address2: | |||||||||
| City: | MORAINE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454391924 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9379913100 | ||||||||
| FaxNumber: | 9372239811 | ||||||||
| Practice Location | |||||||||
| Address1: | 4940 COTTONVILLE RD | ||||||||
| Address2: | |||||||||
| City: | JAMESTOWN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 453351522 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9376756830 | ||||||||
| FaxNumber: | 9376756835 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/13/2006 | ||||||||
| LastUpdateDate: | 03/10/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QS0010X | 35080389 | OH | N | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine | 207Q00000X | 35080389 | OH | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000000666648 | 01 | OH | ANTHEM | OTHER | 000000699778 | 01 | OH | ANTHEM | OTHER | H203790 | 01 | OH | MEDICARE | OTHER | P00954615 | 01 | OH | RRMCR | OTHER | 2436911 | 05 | OH | MEDICAID | 3810017879 | 05 | WV | MEDICAID |