Healthcare Provider Details

I. General information

NPI: 1528053212
Provider Name (Legal Business Name): ANTHONY L. BUCKLES MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/19/2005
Last Update Date: 11/10/2022
Certification Date: 11/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 NORTHGATE RD STE D
NATCHEZ MS
39120-9162
US

IV. Provider business mailing address

105 NORTHGATE RD STE D
NATCHEZ MS
39120-9162
US

V. Phone/Fax

Practice location:
  • Phone: 769-355-2052
  • Fax: 304-803-3716
Mailing address:
  • Phone: 769-355-2052
  • Fax: 304-803-3716

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number036-106738
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number20937
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: