Provider Demographics
NPI:1003813478
Name:BUCKWALTER, KEVIN RAY (MD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:RAY
Last Name:BUCKWALTER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1280 MONUMENT BLVD
Mailing Address - Street 2:# 1
Mailing Address - City:CONCORD
Mailing Address - State:CA
Mailing Address - Zip Code:94520-4405
Mailing Address - Country:US
Mailing Address - Phone:916-733-6993
Mailing Address - Fax:916-733-6989
Practice Address - Street 1:7151 CASCADE VALLEY CT STE 200
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89128-0498
Practice Address - Country:US
Practice Address - Phone:702-568-8450
Practice Address - Fax:702-568-8451
Is Sole Proprietor?:No
Enumeration Date:2005-06-30
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA63401207Q00000X, 208600000X, 208D00000X
NV8476208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA63401OtherLICENSE
NV8476OtherLICENSE
CA00A634010OtherMCARE PTAN
CAG65301Medicare UPIN
CAA63401OtherLICENSE