Healthcare Provider Details

I. General information

NPI: 1184651168
Provider Name (Legal Business Name): WELAKA CLINIC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/27/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

405 ELM ST
WELAKA FL
32193-1110
US

IV. Provider business mailing address

PO BOX 1110
WELAKA FL
32193-1110
US

V. Phone/Fax

Practice location:
  • Phone: 386-467-3171
  • Fax: 386-467-3174
Mailing address:
  • Phone: 386-467-3171
  • Fax: 386-467-3174

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOS0006099
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOS8101
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number17713
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME54534
License Number StateFL
# 5
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberME0059459
License Number StateFL
# 6
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberME85684
License Number StateFL
# 7
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberME75694
License Number StateFL

VIII. Authorized Official

Name: GARY BUCKMAN
Title or Position: ADMINISTRATOR
Credential:
Phone: 386-467-3171