Healthcare Provider Details

I. General information

NPI: 1013273853
Provider Name (Legal Business Name): ANDREW D BUCKLEY D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/05/2012
Last Update Date: 03/03/2025
Certification Date: 03/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2032 TWAIN RIDGE DR
LEXINGTON KY
40514-1325
US

IV. Provider business mailing address

2032 TWAIN RIDGE DR
LEXINGTON KY
40514-1325
US

V. Phone/Fax

Practice location:
  • Phone: 989-780-0613
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number03875
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0116024155
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: