Healthcare Provider Details

I. General information

NPI: 1043320815
Provider Name (Legal Business Name): YETUNDE BUCKNOR MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 10/02/2024
Certification Date: 10/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 GIRARD ST STE 100
GAITHERSBURG MD
20877-3467
US

IV. Provider business mailing address

8665 GEORGIA AVE
SILVER SPRING MD
20910-3405
US

V. Phone/Fax

Practice location:
  • Phone: 301-216-0880
  • Fax: 301-216-2891
Mailing address:
  • Phone: 301-340-7525
  • Fax: 301-495-0318

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberD0075721
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: