Basic Information
| Provider Information | |||||||||
| NPI: | 1306978309 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BUCK | ||||||||
| FirstName: | ANGELES | ||||||||
| MiddleName: | MICHELLE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LOCKARD | ||||||||
| OtherFirstName: | ANGELES | ||||||||
| OtherMiddleName: | MICHELLE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 776351 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606776351 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5025889490 | ||||||||
| FaxNumber: | 5022725116 | ||||||||
| Practice Location | |||||||||
| Address1: | 4123 DUTCHMANS LN | ||||||||
| Address2: | SUITE 601 | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402074707 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5024239595 | ||||||||
| FaxNumber: | 5027190161 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/12/2007 | ||||||||
| LastUpdateDate: | 11/29/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 03118 | KY | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 127009 | 01 | KY | SIHO - WS | OTHER | 50034479 | 01 | KY | PASSPORT - WS | OTHER | 03118 | 01 | KY | STATE LICENSE | OTHER | 2668570 | 01 | KY | CIGNA-WS | OTHER | 000000724271 | 01 | KY | ANTHEM -WS | OTHER | 0000571200 | 01 | KY | HUMANA - WS | OTHER | 201040620 | 05 | IN | MEDICAID | 7100060270 | 05 | KY | MEDICAID | FB0950091 | 01 | KY | DEA | OTHER |