Provider Demographics
NPI:1306893722
Name:BUCK, LEROY SELBY JR (MD)
Entity type:Individual
Prefix:DR
First Name:LEROY
Middle Name:SELBY
Last Name:BUCK
Suffix:JR
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 1:907 EAGLE CT.
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42103-2515
Mailing Address - Country:US
Mailing Address - Phone:270-843-1371
Mailing Address - Fax:
Practice Address - Street 1:237 E. SIXTH ST.
Practice Address - Street 2:
Practice Address - City:RUSSELLVILLE
Practice Address - State:KY
Practice Address - Zip Code:42276-1917
Practice Address - Country:US
Practice Address - Phone:270-726-3629
Practice Address - Fax:270-726-3626
Is Sole Proprietor?:No
Enumeration Date:2006-05-30
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY13284174400000X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY13284OtherSTATE LICENSE
KY13284OtherSTATE LICENSE
KY1205301Medicare ID - Type UnspecifiedPRIVATE PRACTICE
KY13284OtherSTATE LICENSE
KY0570507Medicare ID - Type Unspecified
KYC71533Medicare UPIN
KY0025727Medicare ID - Type Unspecified