Healthcare Provider Details

I. General information

NPI: 1295722635
Provider Name (Legal Business Name): HEIDI BUCKINGHAM MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/30/2005
Last Update Date: 02/04/2022
Certification Date: 02/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 SUGAR CAMP CIR STE 205
OAKWOOD OH
45409-1981
US

IV. Provider business mailing address

3170 KETTERING BLVD BLDG B
MORAINE OH
45439-1924
US

V. Phone/Fax

Practice location:
  • Phone: 937-395-3656
  • Fax: 937-395-3657
Mailing address:
  • Phone: 937-991-3188
  • Fax: 937-223-9811

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number024501
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number35.089021
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: