Provider Demographics
NPI:1700867074
Name:BUCKLE, RAPHAEL A (MD)
Entity Type:Individual
Prefix:DR
First Name:RAPHAEL
Middle Name:A
Last Name:BUCKLE
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 1:900 EARL FRYE BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:AMORY
Mailing Address - State:MS
Mailing Address - Zip Code:38821-5507
Mailing Address - Country:US
Mailing Address - Phone:662-256-9331
Mailing Address - Fax:662-256-9336
Practice Address - Street 1:900 EARL FRYE BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:AMORY
Practice Address - State:MS
Practice Address - Zip Code:38821-5507
Practice Address - Country:US
Practice Address - Phone:662-256-9331
Practice Address - Fax:662-256-9335
Is Sole Proprietor?:No
Enumeration Date:2005-11-14
Last Update Date:2010-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA56408207K00000X, 208000000X
MS20416208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
37BBHBHOtherLEGACY#
GA1184881229OtherORG NPI
MS06304211Medicaid
1700867074OtherNPI
GA262717777AMedicaid
GRP7462OtherGROUP#
GAGRP7462Medicare PIN
GRP7462OtherGROUP#