Provider Demographics
NPI:1649289539
Name:BUCK, STEPHEN GREGORY (OD)
Entity type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:GREGORY
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 1:124 LIMEHOUSE REACH RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29210-4402
Mailing Address - Country:US
Mailing Address - Phone:803-920-2763
Mailing Address - Fax:803-905-8065
Practice Address - Street 1:1283 BROAD ST
Practice Address - Street 2:
Practice Address - City:SUMTER
Practice Address - State:SC
Practice Address - Zip Code:29150-1973
Practice Address - Country:US
Practice Address - Phone:803-920-2763
Practice Address - Fax:803-905-8065
Is Sole Proprietor?:No
Enumeration Date:2006-08-07
Last Update Date:2012-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC591152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCD05910Medicaid
SCP00308477OtherRAILROAD MEDICARE PROV #
SCU419080281Medicare ID - Type Unspecified
SCD05910Medicaid