Basic Information
| Provider Information | |||||||||
| NPI: | 1790951432 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BUCK | ||||||||
| FirstName: | DEREK | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | MD DC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 8310 | ||||||||
| Address2: | |||||||||
| City: | ROANOKE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 240140310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5403453556 | ||||||||
| FaxNumber: | 5403422193 | ||||||||
| Practice Location | |||||||||
| Address1: | 111E SANDERS LN | ||||||||
| Address2: | |||||||||
| City: | BLUEFIELD | ||||||||
| State: | VA | ||||||||
| PostalCode: | 24605 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5405527133 | ||||||||
| FaxNumber: | 5405527143 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/02/2008 | ||||||||
| LastUpdateDate: | 08/08/2018 | ||||||||
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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 | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 208100000X | 0101251939 | VA | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 182259001 | 05 | AR | MEDICAID |