Healthcare Provider Details

I. General information

NPI: 1700867074
Provider Name (Legal Business Name): RAPHAEL A BUCKLE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2005
Last Update Date: 03/02/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 EARL FRYE BLVD SUITE A
AMORY MS
38821-5507
US

IV. Provider business mailing address

900 EARL FRYE BLVD SUITE A
AMORY MS
38821-5507
US

V. Phone/Fax

Practice location:
  • Phone: 662-256-9331
  • Fax: 662-256-9335
Mailing address:
  • Phone: 662-256-9331
  • Fax: 662-256-9336

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number56408
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number56408
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number20416
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: