Healthcare Provider Details

I. General information

NPI: 1962620666
Provider Name (Legal Business Name): BRADLEY C BUCKHOUT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2006
Last Update Date: 01/08/2015
Certification Date:
Deactivation Date: 10/25/2006
Reactivation Date: 04/20/2007

III. Provider practice location address

650 E INDIAN SCHOOL RD CLC
PHOENIX AZ
85012-1839
US

IV. Provider business mailing address

650 E INDIAN SCHOOL RD CLC
PHOENIX AZ
85012-1839
US

V. Phone/Fax

Practice location:
  • Phone: 602-277-5551
  • Fax: 602-200-6039
Mailing address:
  • Phone: 602-277-5551
  • Fax: 602-200-6039

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number13405
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number13405
License Number StateAZ
# 3
Primary TaxonomyY
Taxonomy Code207QH0002X
TaxonomyHospice and Palliative Medicine (Family Medicine) Physician
License Number13405
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: