Healthcare Provider Details

I. General information

NPI: 1912060179
Provider Name (Legal Business Name): JOHN WILLIAM BUCKLEY JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/19/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5220 LONG GREEN RD
GLEN ARM MD
21057-9716
US

IV. Provider business mailing address

5220 LONG GREEN RD
GLEN ARM MD
21057-9716
US

V. Phone/Fax

Practice location:
  • Phone: 410-592-5955
  • Fax:
Mailing address:
  • Phone: 410-592-5955
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberD0013364
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: