Healthcare Provider Details

I. General information

NPI: 1568484855
Provider Name (Legal Business Name): KEVIN BUCKMAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2006
Last Update Date: 11/02/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

975 S FAIRMONT AVE
LODI CA
95240-5118
US

IV. Provider business mailing address

5937 CUMBERLAND PL
STOCKTON CA
95219-3818
US

V. Phone/Fax

Practice location:
  • Phone: 209-339-7575
  • Fax:
Mailing address:
  • Phone: 209-610-5000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberA33983
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2083X0100X
TaxonomyOccupational Medicine Physician
License NumberA33983
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: