Provider Demographics
NPI:1528053212
Name:BUCKLES, ANTHONY L (MD)
Entity type:Individual
Prefix:
First Name:ANTHONY
Middle Name:L
Last Name:BUCKLES
Suffix:
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 1:105 NORTHGATE RD STE D
Mailing Address - Street 2:
Mailing Address - City:NATCHEZ
Mailing Address - State:MS
Mailing Address - Zip Code:39120-9162
Mailing Address - Country:US
Mailing Address - Phone:769-355-2052
Mailing Address - Fax:304-803-3716
Practice Address - Street 1:105 NORTHGATE RD STE D
Practice Address - Street 2:
Practice Address - City:NATCHEZ
Practice Address - State:MS
Practice Address - Zip Code:39120-9162
Practice Address - Country:US
Practice Address - Phone:769-355-2052
Practice Address - Fax:304-803-3716
Is Sole Proprietor?:No
Enumeration Date:2005-09-19
Last Update Date:2022-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-106738207P00000X
MS20937207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS004230014Medicaid
ILH33627Medicare UPIN
LA2111833Medicare PIN