1922064336 NPI number — REGINA BUCKLEY DANDY DO

Table of content: (NPI 1790928893)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922064336 NPI number — REGINA BUCKLEY DANDY DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DANDY
Provider First Name:
REGINA
Provider Middle Name:
BUCKLEY
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BUCKLEY
Provider Other First Name:
REGINA
Provider Other Middle Name:
L.
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
DO
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1922064336
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/02/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 15849
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAVANNAH
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31416-2549
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
912-527-5301
Provider Business Mailing Address Fax Number:
912-756-4740

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
89 INTERCHANGE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RICHMOND HILL
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31324-7661
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
912-527-5301
Provider Business Practice Location Address Fax Number:
912-756-4740
Provider Enumeration Date:
04/25/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  057286 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 046401246D , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 404141 . This is a "WELLCARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 046401246A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 10069519 . This is a "AMERIGROUP" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: GRP3905 . This is a "GA MEDICARE GROUP ID" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: P00394151 . This is a "RR MEDICARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 046401246B , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: CH5121 . This is a "RR MEDICARE GROUP ID" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: G57286 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 52206024-001 . This is a "BCBS GA" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 046401246C , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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