Healthcare Provider Details

I. General information

NPI: 1659587871
Provider Name (Legal Business Name): TAVIS SCOTT BUCKINGHAM IDC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/15/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

USS NEW ORLEANS (LPD 18) FPO AP 96673-1701 COMMANDING OFFICER
SAN DIEGO CA
92123
US

IV. Provider business mailing address

4837 SHIELDS ST
SAN DIEGO CA
92124-2930
US

V. Phone/Fax

Practice location:
  • Phone: 619-849-1480
  • Fax:
Mailing address:
  • Phone: 858-822-8904
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1002X
TaxonomyIndependent Duty Corpsman
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: