Healthcare Provider Details

I. General information

NPI: 1750728499
Provider Name (Legal Business Name): ANDREW ROBERT BUCKLEY D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2013
Last Update Date: 08/26/2024
Certification Date: 08/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

411 E CHESTNUT ST
LOUISVILLE KY
40202-1713
US

IV. Provider business mailing address

PO BOX 909
LOUISVILLE KY
40201-0909
US

V. Phone/Fax

Practice location:
  • Phone: 502-588-2330
  • Fax:
Mailing address:
  • Phone: 502-588-2330
  • Fax: 502-588-9513

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080P0204X
TaxonomyPediatric Emergency Medicine (Pediatrics) Physician
License Number34.013557
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License Number04541
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: