Provider Demographics
NPI:1790951432
Name:BUCK, DEREK S (MD DC)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:S
Last Name:BUCK
Suffix:
Gender:M
Credentials:MD DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 8310
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24014-0310
Mailing Address - Country:US
Mailing Address - Phone:540-345-3556
Mailing Address - Fax:540-342-2193
Practice Address - Street 1:111E SANDERS LN
Practice Address - Street 2:
Practice Address - City:BLUEFIELD
Practice Address - State:VA
Practice Address - Zip Code:24605
Practice Address - Country:US
Practice Address - Phone:540-552-7133
Practice Address - Fax:540-552-7143
Is Sole Proprietor?:No
Enumeration Date:2008-05-02
Last Update Date:2018-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
VA0101251939208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR182259001Medicaid
ARU49602Medicare UPIN
AR182259001Medicaid