Healthcare Provider Details

I. General information

NPI: 1174733083
Provider Name (Legal Business Name): DUSTAN P BUCKLEY MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/23/2007
Last Update Date: 08/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4140 W MEMORIAL RD SUITE 303
OKLAHOMA CITY OK
73120-8366
US

IV. Provider business mailing address

PO BOX 3967
EDMOND OK
73083-3967
US

V. Phone/Fax

Practice location:
  • Phone: 405-749-7030
  • Fax: 405-292-5505
Mailing address:
  • Phone: 405-749-7030
  • Fax: 405-292-5505

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number18504
License Number StateOK

VIII. Authorized Official

Name: DUSTAN P BUCKLEY
Title or Position: PRESIDENT
Credential: MD
Phone: 405-749-7030