1063670503 NPI number — MATTHEW BUCKLER MD

Table of content: MATTHEW BUCKLER MD (NPI 1063670503)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063670503 NPI number — MATTHEW BUCKLER MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BUCKLER
Provider First Name:
MATTHEW
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1063670503
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/06/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
27005 76TH AVE
Provider Second Line Business Mailing Address:
DEPARTMENT OF RADIOLOGY, LONG ISLAND JEWISH MEDICAL CEN
Provider Business Mailing Address City Name:
NEW HYDE PARK
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11040-1402
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
718-470-4585
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
59 EXECUTIVE PARK DR.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ATLANTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30329
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-597-0886
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/31/2008

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: 2085R0202X , with the licence number:  2559651 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 104283800 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com