Provider Demographics
NPI:1295850824
Name:STEPHEN BUCK
Entity Type:Organization
Organization Name:STEPHEN BUCK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:G
Authorized Official - Last Name:BUCK
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:252-985-1371
Mailing Address - Street 1:P O BOX 7396
Mailing Address - Street 2:
Mailing Address - City:ROCKY MOUNT
Mailing Address - State:NC
Mailing Address - Zip Code:27804-4837
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1855 E MAIN ST
Practice Address - Street 2:STE 14, TMB 151
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29307-2309
Practice Address - Country:US
Practice Address - Phone:252-985-1371
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-20
Last Update Date:2008-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC591152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCD05910Medicaid
SCP00308477OtherRR MEDICARE PROV #
SCD05910Medicaid