Provider Demographics
NPI:1205829199
Name:BUCKALEW, ZACK THERRELL III (MD)
Entity Type:Individual
Prefix:
First Name:ZACK
Middle Name:THERRELL
Last Name:BUCKALEW
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 13030
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:LA
Mailing Address - Zip Code:71315-3030
Mailing Address - Country:US
Mailing Address - Phone:318-445-9331
Mailing Address - Fax:318-619-6899
Practice Address - Street 1:176 VERSAILLES BLVD
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:LA
Practice Address - Zip Code:71303-2493
Practice Address - Country:US
Practice Address - Phone:318-445-9331
Practice Address - Fax:318-619-6899
Is Sole Proprietor?:No
Enumeration Date:2005-08-25
Last Update Date:2020-09-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
LA012656207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1182397Medicaid
LA1182397Medicaid
LA5J108Medicare ID - Type Unspecified