Healthcare Provider Details

I. General information

NPI: 1134128051
Provider Name (Legal Business Name): CHARLES EDWARD BUCKLEY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2005
Last Update Date: 03/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4700 BERWYN HOUSE RD SUITE 102
COLLEGE PARK MD
20740-2474
US

IV. Provider business mailing address

4700 BERWYN HOUSE RD SUITE 207
COLLEGE PARK MD
20740-2474
US

V. Phone/Fax

Practice location:
  • Phone: 301-345-0406
  • Fax: 301-345-0409
Mailing address:
  • Phone: 301-220-0150
  • Fax: 301-220-1032

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085N0904X
TaxonomyNuclear Radiology Physician
License NumberD16341
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code2085N0904X
TaxonomyNuclear Radiology Physician
License NumberMD25540
License Number StateDC
# 3
Primary TaxonomyN
Taxonomy Code2085N0904X
TaxonomyNuclear Radiology Physician
License Number019671
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: