Provider Demographics
NPI:1417968637
Name:LAKE JACKSON IMAGING CENTER
Entity Type:Organization
Organization Name:LAKE JACKSON IMAGING CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:E
Authorized Official - Last Name:BUCK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:936-203-5996
Mailing Address - Street 1:217 OAK DR S
Mailing Address - Street 2:SUITE A
Mailing Address - City:LAKE JACKSON
Mailing Address - State:TX
Mailing Address - Zip Code:77566-5675
Mailing Address - Country:US
Mailing Address - Phone:979-297-2800
Mailing Address - Fax:
Practice Address - Street 1:217 OAK DRIVE SOUTH SUITE A
Practice Address - Street 2:
Practice Address - City:LAKE JACKSON
Practice Address - State:TX
Practice Address - Zip Code:77566
Practice Address - Country:US
Practice Address - Phone:979-297-2800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-11
Last Update Date:2008-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX261QR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology