Provider Demographics
NPI:1588600662
Name:BUCKELEW, DARYL QUINTIN (MD)
Entity type:Individual
Prefix:
First Name:DARYL
Middle Name:QUINTIN
Last Name:BUCKELEW
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 38150
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71133-8150
Mailing Address - Country:US
Mailing Address - Phone:318-631-9121
Mailing Address - Fax:318-631-9126
Practice Address - Street 1:3217 MABEL ST
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71103-4022
Practice Address - Country:US
Practice Address - Phone:318-631-9121
Practice Address - Fax:318-631-9126
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2024-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK6994207RG0100X
LA340576207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2654055Medicaid
G85171Medicare UPIN
TX8G8385Medicare Oscar/Certification