Healthcare Provider Details

I. General information

NPI: 1871561092
Provider Name (Legal Business Name): RONALD L BUCKMAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/14/2006
Last Update Date: 07/26/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

921 BOSTON TPKE
BOLTON CT
06043-7403
US

IV. Provider business mailing address

921 BOSTON TPKE
BOLTON CT
06043-7403
US

V. Phone/Fax

Practice location:
  • Phone: 860-646-0649
  • Fax: 860-649-9195
Mailing address:
  • Phone: 860-646-0649
  • Fax: 860-649-9195

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number022901
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number022901
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: