Healthcare Provider Details

I. General information

NPI: 1740663103
Provider Name (Legal Business Name): BRENT BUCCINE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2015
Last Update Date: 07/18/2022
Certification Date: 07/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34800 BOB WILSON DR
SAN DIEGO CA
92134-1098
US

IV. Provider business mailing address

4909 WICOMICO AVE
BELTSVILLE MD
20705-1914
US

V. Phone/Fax

Practice location:
  • Phone: 619-532-7935
  • Fax:
Mailing address:
  • Phone: 301-908-8197
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number0101260823
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: