Provider Demographics
NPI:1437195377
Name:VANBUECKEN, KENT PAUL (MD)
Entity Type:Individual
Prefix:
First Name:KENT
Middle Name:PAUL
Last Name:VANBUECKEN
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:PO BOX 5127
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37602-5127
Mailing Address - Country:US
Mailing Address - Phone:423-952-2122
Mailing Address - Fax:423-952-2145
Practice Address - Street 1:96 15TH ST NW
Practice Address - Street 2:SUITE 111
Practice Address - City:NORTON
Practice Address - State:VA
Practice Address - Zip Code:24273-1620
Practice Address - Country:US
Practice Address - Phone:276-439-1463
Practice Address - Fax:276-439-1464
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00026111207X00000X
WAMD0002611207XX0005X
VA0101255623207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1437195377Medicaid
4586750OtherAETNA
TNQ004984Medicaid
VAP01415097OtherRR MEDICARE
VAP01415097OtherRR MEDICARE
4586750OtherAETNA
VA1437195377Medicaid
TNQ004984Medicaid
G8887636Medicare PIN
G8900266Medicare PIN
200022996OtherRAILROAD MEDICARE
E53843Medicare UPIN
WA1302082Medicaid
WAG8851968Medicare PIN
WA104796OtherLABOR & INDUSTRIES
4586750OtherAETNA
VAC10456Medicare UPIN
VA1437195377Medicaid
WAG000250459Medicare PIN
VAVVF382AMedicare PIN