Healthcare Provider Details

I. General information

NPI: 1801355607
Provider Name (Legal Business Name): ANDREW MADISON BUCKELEW DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/19/2019
Last Update Date: 06/06/2025
Certification Date: 05/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 JOHNSON FERRY RD
ATLANTA GA
30342-1605
US

IV. Provider business mailing address

1001 JOHNSON FY RD NE
ATLANTA GA
30342-1605
US

V. Phone/Fax

Practice location:
  • Phone: 678-344-1960
  • Fax: 404-785-9168
Mailing address:
  • Phone: 678-344-1960
  • Fax: 404-907-4257

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number99101
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberOS18983
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number30451
License Number StateMS
# 4
Primary TaxonomyY
Taxonomy Code2080P0204X
TaxonomyPediatric Emergency Medicine (Pediatrics) Physician
License Number99101
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: