Healthcare Provider Details

I. General information

NPI: 1154344398
Provider Name (Legal Business Name): BRIAN A BUCKLER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2006
Last Update Date: 09/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1471 EAST BELTLINE STE 201
GRAND RAPIDS MI
49525
US

IV. Provider business mailing address

245 STATE ST SE STE 228
GRAND RAPIDS MI
49503
US

V. Phone/Fax

Practice location:
  • Phone: 616-685-8620
  • Fax: 616-447-7674
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4301084540
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: