Healthcare Provider Details

I. General information

NPI: 1558795757
Provider Name (Legal Business Name): CANDACE J BUCKLEY DPM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/25/2013
Last Update Date: 12/02/2021
Certification Date: 12/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11332 MOUNTAIN VIEW AVE STE A
LOMA LINDA CA
92354-3854
US

IV. Provider business mailing address

585 SCHENECTADY AVE DEPT OF ORTHOPEDICS/PODIATRY
BROOKLYN NY
11203-1851
US

V. Phone/Fax

Practice location:
  • Phone: 909-796-3707
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberR80330
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License NumberR80330
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code213ER0200X
TaxonomyRadiology Podiatrist
License NumberR80330
License Number StateNY
# 4
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberR80330
License Number StateNY
# 5
Primary TaxonomyN
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License NumberR80330
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: