Healthcare Provider Details

I. General information

NPI: 1528171881
Provider Name (Legal Business Name): ALICIA DANIELLE BUCKO DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1203 COAL AVE SE
ALBUQUERQUE NM
87106-5239
US

IV. Provider business mailing address

1203 COAL AVE SE
ALBUQUERQUE NM
87106-5239
US

V. Phone/Fax

Practice location:
  • Phone: 505-247-4220
  • Fax: 505-247-0367
Mailing address:
  • Phone: 505-247-4220
  • Fax: 505-247-0367

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberA795-84
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: