Provider Demographics
NPI:1215294327
Name:BUCKNER, JOHN WORDY IV (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:WORDY
Last Name:BUCKNER
Suffix:IV
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4629 PEPPER MILL ST
Mailing Address - Street 2:
Mailing Address - City:MOORPARK
Mailing Address - State:CA
Mailing Address - Zip Code:93021-2408
Mailing Address - Country:US
Mailing Address - Phone:417-773-1945
Mailing Address - Fax:
Practice Address - Street 1:1600 N ROSE AVE
Practice Address - Street 2:
Practice Address - City:OXNARD
Practice Address - State:CA
Practice Address - Zip Code:93030-3722
Practice Address - Country:US
Practice Address - Phone:805-988-2500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-13
Last Update Date:2022-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2014021729207P00000X
CA157401207P00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1215294327Medicaid
MO678000015Medicare PIN