Healthcare Provider Details

I. General information

NPI: 1063402667
Provider Name (Legal Business Name): MICHAEL GURDON BUCK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/25/2005
Last Update Date: 02/28/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1587 N BOLTON AVE SUITE 1100
ALEXANDRIA LA
71303-4217
US

IV. Provider business mailing address

1587 N BOLTON AVE SUITE 1100
ALEXANDRIA LA
71303-4217
US

V. Phone/Fax

Practice location:
  • Phone: 318-473-4500
  • Fax: 318-445-1509
Mailing address:
  • Phone: 318-473-4500
  • Fax: 318-445-1509

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number015029
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: