Provider Demographics
NPI:1558845362
Name:BUCKNER, WALTER (IDMT)
Entity Type:Individual
Prefix:
First Name:WALTER
Middle Name:
Last Name:BUCKNER
Suffix:
Gender:M
Credentials:IDMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 POST AVE
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37777-6223
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:420 POST AVE
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:TN
Practice Address - Zip Code:37777-6223
Practice Address - Country:US
Practice Address - Phone:931-698-7906
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-18
Last Update Date:2018-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians