Provider Demographics
NPI:1578697207
Name:BUCKNELL, MICHAEL DAVID (DC)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:DAVID
Last Name:BUCKNELL
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 1:7921 TANNER WILLIAMS RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36608-8308
Mailing Address - Country:US
Mailing Address - Phone:251-607-0040
Mailing Address - Fax:251-607-7202
Practice Address - Street 1:7921 TANNER WILLIAMS RD
Practice Address - Street 2:SUITE B
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36608-8308
Practice Address - Country:US
Practice Address - Phone:251-607-0040
Practice Address - Fax:251-607-7202
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-15
Last Update Date:2012-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL2091111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL529922410Medicaid
ALZ02058OtherVIVAHEALTH PROVIDER NUM
ALV06119OtherHEALTHSPRING PROVIDER NUM
AL009983115Medicaid
AL#01465OtherBCBS UPIN
AL51523710OtherBCBS PROVIDER NUMBER
ALZ02058OtherVIVAHEALTH PROVIDER NUM
AL009983115Medicaid