Healthcare Provider Details

I. General information

NPI: 1598788507
Provider Name (Legal Business Name): VICTORIA RUTH BUCKNER DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2006
Last Update Date: 03/07/2023
Certification Date: 01/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2115 LEITER RD SYCAMORE PRIMARY CARE GROUP
MIAMISBURG OH
45342-3659
US

IV. Provider business mailing address

6661 CLYO RD
CENTERVILLE OH
45459-2702
US

V. Phone/Fax

Practice location:
  • Phone: 937-384-6800
  • Fax: 937-384-6939
Mailing address:
  • Phone: 937-425-4000
  • Fax: 937-425-4002

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number2006-01029
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number34009103
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: