Provider Demographics
NPI:1689803355
Name:BUCHANAN, JUSTIN TODD (MD)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:TODD
Last Name:BUCHANAN
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 1:527 N PALO ALTO AVE
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32401-3639
Mailing Address - Country:US
Mailing Address - Phone:850-747-4905
Mailing Address - Fax:850-747-4907
Practice Address - Street 1:1924 ALCOA HWY # U107
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37920-1511
Practice Address - Country:US
Practice Address - Phone:865-305-9661
Practice Address - Fax:865-305-6148
Is Sole Proprietor?:No
Enumeration Date:2009-07-02
Last Update Date:2019-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME1267872085R0202X
NC2018-030072085R0202X
TN466892085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLIM424YOtherMEDICARE PTAN
FLKZBPLOtherBCBS
FL016743700Medicaid
FLIM424ZOtherMEDICARE PTAN
FLP01664307OtherRAILROAD MEDICARE
FLIM424XOtherMEDICARE PTAN