Healthcare Provider Details

I. General information

NPI: 1558388090
Provider Name (Legal Business Name): THOMAS M BUCKLEY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2006
Last Update Date: 12/27/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 ORCHARD ST SUITE 164
NEW HAVEN CT
06511-4417
US

IV. Provider business mailing address

789 HOWARD AVE # FMP305 PO BOX 208058
NEW HAVEN CT
06519-1304
US

V. Phone/Fax

Practice location:
  • Phone: 203-785-2815
  • Fax: 203-785-4043
Mailing address:
  • Phone: 203-785-5339
  • Fax: 203-785-4043

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number029419
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: