Provider Demographics
NPI:1861847790
Name:BUCK, JONATHAN BOHANNON (MD, MPH)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:BOHANNON
Last Name:BUCK
Suffix:
Gender:M
Credentials:MD, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2340 LAFAYETTE AVE
Mailing Address - Street 2:UNIT 3K
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63104-2516
Mailing Address - Country:US
Mailing Address - Phone:314-780-7625
Mailing Address - Fax:
Practice Address - Street 1:1402 S GRAND BLVD
Practice Address - Street 2:14TH FLOOR FDT
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63104-1004
Practice Address - Country:US
Practice Address - Phone:314-577-8762
Practice Address - Fax:314-577-8100
Is Sole Proprietor?:No
Enumeration Date:2016-04-28
Last Update Date:2022-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2021012535208M00000X, 207R00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program