Provider Demographics
NPI:1659587871
Name:BUCKINGHAM, TAVIS SCOTT (IDC)
Entity Type:Individual
Prefix:MR
First Name:TAVIS
Middle Name:SCOTT
Last Name:BUCKINGHAM
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4837 SHIELDS ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92124-2930
Mailing Address - Country:US
Mailing Address - Phone:858-822-8904
Mailing Address - Fax:
Practice Address - Street 1:USS NEW ORLEANS (LPD 18) FPO AP 96673-1701
Practice Address - Street 2:COMMANDING OFFICER
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123
Practice Address - Country:US
Practice Address - Phone:619-849-1480
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1710I1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman