Provider Demographics
NPI:1689672420
Name:BUCK, J. WAYNE (OD)
Entity Type:Individual
Prefix:
First Name:J.
Middle Name:WAYNE
Last Name:BUCK
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1602 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CROSSETT
Mailing Address - State:AR
Mailing Address - Zip Code:71635-4154
Mailing Address - Country:US
Mailing Address - Phone:870-364-8996
Mailing Address - Fax:870-364-7363
Practice Address - Street 1:1602 MAIN ST
Practice Address - Street 2:
Practice Address - City:CROSSETT
Practice Address - State:AR
Practice Address - Zip Code:71635-4154
Practice Address - Country:US
Practice Address - Phone:870-364-8996
Practice Address - Fax:870-364-7363
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2246152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR49206B391Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER
ART20291Medicare UPIN