Provider Demographics
NPI:1447268560
Name:BUCKLES, RANDY SCOTT (DO)
Entity type:Individual
Prefix:DR
First Name:RANDY
Middle Name:SCOTT
Last Name:BUCKLES
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 SOUTH WOODBINE RD
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MO
Mailing Address - Zip Code:64506
Mailing Address - Country:US
Mailing Address - Phone:816-676-1300
Mailing Address - Fax:816-676-1400
Practice Address - Street 1:220 SOUTH WOODBINE RD
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MO
Practice Address - Zip Code:64506
Practice Address - Country:US
Practice Address - Phone:816-676-1300
Practice Address - Fax:816-676-1400
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2009-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO108739207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO24918021OtherBCKC PROVIDER ID
MO431812629OtherWPS TRICARE FOR LIFE
MO249770702Medicaid
MO27020012OtherBCKC GROUP ID #
MO505804906Medicaid
MO2326850OtherAETNA PROVIDER ID
MO385996OtherHEALTHLINK PROVIDER #
MO080128455OtherRAILROAD RETIR BRD PRO #
MO10001359400OtherCOMUUNITY HEALTH PLAN #
MO100001359400OtherCHP PROVIDER #
MO45828OtherHEALTHLINK GRP #
MO080128455OtherRAILROAD RETIR. BRD GRP #
MO385996OtherFREEDOM/HEALTHLINK
MO249770702Medicaid
MO4761830001Medicare NSC
MOK368324Medicare PIN