Healthcare Provider Details

I. General information

NPI: 1255384111
Provider Name (Legal Business Name): TERESA A. BUCKSTEIN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2006
Last Update Date: 07/27/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2525 E ROOSEVELT ST
PHOENIX AZ
85008-4948
US

IV. Provider business mailing address

PO BOX 5177
PHOENIX AZ
85010-5177
US

V. Phone/Fax

Practice location:
  • Phone: 602-344-5651
  • Fax: 602-344-5578
Mailing address:
  • Phone: 602-344-5651
  • Fax: 602-344-5578

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number14781
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: