Basic Information
| Provider Information | |||||||||
| NPI: | 1922064336 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DANDY | ||||||||
| FirstName: | REGINA | ||||||||
| MiddleName: | BUCKLEY | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BUCKLEY | ||||||||
| OtherFirstName: | REGINA | ||||||||
| OtherMiddleName: | L. | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | DO | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 15849 | ||||||||
| Address2: | |||||||||
| City: | SAVANNAH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 314162549 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9125275301 | ||||||||
| FaxNumber: | 9127564740 | ||||||||
| Practice Location | |||||||||
| Address1: | 89 INTERCHANGE DR | ||||||||
| Address2: | |||||||||
| City: | RICHMOND HILL | ||||||||
| State: | GA | ||||||||
| PostalCode: | 313247661 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9125275301 | ||||||||
| FaxNumber: | 9127564740 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/25/2006 | ||||||||
| LastUpdateDate: | 09/02/2016 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 057286 | GA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 046401246D | 05 | GA | MEDICAID | 404141 | 01 | GA | WELLCARE | OTHER | 046401246A | 05 | GA | MEDICAID | 10069519 | 01 | GA | AMERIGROUP | OTHER | GRP3905 | 01 | GA | GA MEDICARE GROUP ID | OTHER | P00394151 | 01 | GA | RR MEDICARE | OTHER | 046401246B | 05 | GA | MEDICAID | CH5121 | 01 | GA | RR MEDICARE GROUP ID | OTHER | G57286 | 05 | SC | MEDICAID | 52206024-001 | 01 | GA | BCBS GA | OTHER | 046401246C | 05 | GA | MEDICAID |