Provider Demographics
NPI:1598788507
Name:BUCKNER, VICTORIA RUTH (DO)
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:RUTH
Last Name:BUCKNER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6661 CLYO RD
Mailing Address - Street 2:
Mailing Address - City:CENTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45459-2702
Mailing Address - Country:US
Mailing Address - Phone:937-425-4000
Mailing Address - Fax:937-425-4002
Practice Address - Street 1:2115 LEITER RD
Practice Address - Street 2:SYCAMORE PRIMARY CARE GROUP
Practice Address - City:MIAMISBURG
Practice Address - State:OH
Practice Address - Zip Code:45342-3659
Practice Address - Country:US
Practice Address - Phone:937-384-6800
Practice Address - Fax:937-384-6939
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2006-01029207R00000X
OH34009103207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC190798OtherMEDCOST
NC808057OtherPARTNERS MEDICARE CH
7345780OtherAETNA
NC190798OtherMEDCOST ID
NC14214OtherBCBS ID
NCP00328842OtherRAILROAD MEDICARE ID
NC14214OtherBCBSNC
OH2767439Medicaid
NC5904460Medicaid
NC566000156OtherPRATICE TAX ID
NC7345780OtherAETNA ID
NC808057OtherPARTNERS MEDICARE CHOICE
OH311446216OtherPRACTICE TAX ID #
OH311446216OtherPRACTICE TAX ID #
NCBB9846619OtherDEA
OH2767439Medicaid
OH311446216OtherPRACTICE TAX ID #
OHBU4223541Medicare PIN
NC2403142AMedicare PIN