Provider Demographics
NPI:1003836669
Name:BUCKNER, IRENE (MD)
Entity Type:Individual
Prefix:
First Name:IRENE
Middle Name:
Last Name:BUCKNER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1967 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:CLARKSDALE
Mailing Address - State:MS
Mailing Address - Zip Code:38614-7203
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1967 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:CLARKSDALE
Practice Address - State:MS
Practice Address - Zip Code:38614
Practice Address - Country:US
Practice Address - Phone:662-624-5481
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2019-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS16074174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00119669Medicaid
110001117Medicare ID - Type Unspecified
MS00119669Medicaid