Healthcare Provider Details

I. General information

NPI: 1003135377
Provider Name (Legal Business Name): TIMOTHY ANTHONY BUCKLEY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2010
Last Update Date: 12/17/2024
Certification Date: 12/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 S CLINTON ST
BALTIMORE MD
21224-5730
US

IV. Provider business mailing address

1 LIBERTY PLZ STE 301
NEW YORK NY
10006-1404
US

V. Phone/Fax

Practice location:
  • Phone: 866-763-2211
  • Fax:
Mailing address:
  • Phone: 917-261-4414
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number147954
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036132513
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberD0096374
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: