Provider Demographics
NPI:1154685972
Name:BANIA, BUCK (MD)
Entity Type:Individual
Prefix:DR
First Name:BUCK
Middle Name:
Last Name:BANIA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2310 4TH AVE N
Mailing Address - Street 2:
Mailing Address - City:MOORHEAD
Mailing Address - State:MN
Mailing Address - Zip Code:56560-2473
Mailing Address - Country:US
Mailing Address - Phone:218-422-7439
Mailing Address - Fax:
Practice Address - Street 1:2310 4TH AVE N
Practice Address - Street 2:
Practice Address - City:MOORHEAD
Practice Address - State:MN
Practice Address - Zip Code:56560-2473
Practice Address - Country:US
Practice Address - Phone:218-422-7439
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-26
Last Update Date:2023-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN56478207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNP01249783OtherRAILROAD MEDICARE
MN080023958Medicare PIN