Provider Demographics
NPI:1609849264
Name:BUCK, DAVID P (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:P
Last Name:BUCK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3170 KETTERING BLVD BLDG B3
Mailing Address - Street 2:
Mailing Address - City:MORAINE
Mailing Address - State:OH
Mailing Address - Zip Code:45439-1924
Mailing Address - Country:US
Mailing Address - Phone:937-991-3100
Mailing Address - Fax:937-223-9811
Practice Address - Street 1:4940 COTTONVILLE RD
Practice Address - Street 2:
Practice Address - City:JAMESTOWN
Practice Address - State:OH
Practice Address - Zip Code:45335-1522
Practice Address - Country:US
Practice Address - Phone:937-675-6830
Practice Address - Fax:937-675-6835
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-13
Last Update Date:2021-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35080389207QS0010X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000666648OtherANTHEM
OH000000699778OtherANTHEM
OHH203790OtherMEDICARE
OHP00954615OtherRRMCR
OH2436911Medicaid
WV3810017879Medicaid
OHP00954615OtherRRMCR
OH000000666648OtherANTHEM
OHH87927Medicare UPIN
WV3810017879Medicaid