Provider Demographics
NPI:1538283833
Name:BUCKLEY, GERARD KEVIN (DC)
Entity Type:Individual
Prefix:DR
First Name:GERARD
Middle Name:KEVIN
Last Name:BUCKLEY
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2765 REBECCA LN
Mailing Address - Street 2:SUITE D
Mailing Address - City:ORANGE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32763-8326
Mailing Address - Country:US
Mailing Address - Phone:386-775-1422
Mailing Address - Fax:386-775-1415
Practice Address - Street 1:2765 REBECCA LN
Practice Address - Street 2:STE. D
Practice Address - City:ORANGE CITY
Practice Address - State:FL
Practice Address - Zip Code:32763-8326
Practice Address - Country:US
Practice Address - Phone:386-775-1422
Practice Address - Fax:386-775-1415
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-19
Last Update Date:2014-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH8641111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000043400Medicaid
FL000043400Medicaid