Provider Demographics
NPI:1366525750
Name:BUCK, DANNIE EARL (MD)
Entity type:Individual
Prefix:
First Name:DANNIE
Middle Name:EARL
Last Name:BUCK
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:PO BOX 730607
Mailing Address - Street 2:
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32173-0607
Mailing Address - Country:US
Mailing Address - Phone:386-676-0505
Mailing Address - Fax:386-676-0788
Practice Address - Street 1:800 S NOVA RD
Practice Address - Street 2:SUITE A
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-7362
Practice Address - Country:US
Practice Address - Phone:386-676-0505
Practice Address - Fax:386-676-0788
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-23
Last Update Date:2010-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME62671207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL371526400Medicaid
FL18282AMedicare ID - Type Unspecified
FL371526400Medicaid