Provider Demographics
NPI:1740251198
Name:BUCK, STANLEY W (MD)
Entity type:Individual
Prefix:
First Name:STANLEY
Middle Name:W
Last Name:BUCK
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 1:11125 DUNN RD
Mailing Address - Street 2:STE 304
Mailing Address - City:ST LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63136
Mailing Address - Country:US
Mailing Address - Phone:314-355-1166
Mailing Address - Fax:314-355-4385
Practice Address - Street 1:11125 DUNN RD
Practice Address - Street 2:STE 304
Practice Address - City:ST LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63136
Practice Address - Country:US
Practice Address - Phone:314-355-1166
Practice Address - Fax:314-355-4385
Is Sole Proprietor?:No
Enumeration Date:2006-02-01
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036068435207RN0300X
MOMDR8729207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO201520111Medicaid
IL973041Medicare PIN
A10146Medicare UPIN
MO201520111Medicaid