Healthcare Provider Details

I. General information

NPI: 1558372805
Provider Name (Legal Business Name): TIMOTHY J BUCKLEY DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 KILLINGWORTH RD
HIGGANUM CT
06441-4370
US

IV. Provider business mailing address

4 FARM SPRINGS RD PROHEALTH PHYSICIANS
FARMINGTON CT
06032-2573
US

V. Phone/Fax

Practice location:
  • Phone: 860-345-8535
  • Fax: 860-345-8678
Mailing address:
  • Phone: 860-284-5200
  • Fax: 860-284-5333

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number038815
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: